Anaesthesia in the obese patient

Obesity is an increasing problem and its burden on healthcare resources is well documented | Anaesthesia and Intensive Care Medicine

This article gives an overview of the physiological and pharmacological considerations when anaesthetizing the obese patient. It will look at key aspects of assessing obese patients, and planning and delivering a safe anaesthetic to them. Special areas of focus include correct drug dosing, as well as equipment, monitoring and environmental aspects involved in delivering the anaesthetic.

Full reference: Nelson, G &  Clayton, R. (2017) Anaesthesia in the obese patient. Anaesthesia and Intensive Care Medicine. Published online: 14 August 2017

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

Bugada D1, Allegri M, Gemma M at al. Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study. Eur J Anaesthesiol. 2017 Aug 1. doi: 10.1097/EJA.0000000000000656. [Epub ahead of print]

BACKGROUND: Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA).

OBJECTIVES: Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA.

DESIGN: A web-based prospective observational registry.

SETTING: Five Italian Private and University Hospitals from 2012 to 2015.

PATIENTS: Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery.

INTERVENTION(S): Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability.

MAIN OUTCOME MEASURES: Experience of PPSP according to the type of peri-operative analgesia.

RESULTS: Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months.

CONCLUSION: Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP.

Anaesthesia for maxillofacial surgery

Airway management is central to anaesthesia for maxillofacial surgery. Not only is there a shared airway to contend with, difficult airways are frequently encountered | Anaesthesia and Intensive Care Medicine 

The main pathologies that present for surgery include trauma, infection, cancer and craniofacial deformities. All of these may present an airway challenge in either elective or emergency settings but a similar approach to the airway can be used in all these scenarios. Other surgical procedures include dental extractions, temporomandibular joint (TMJ) arthrocentesis, salivary gland surgery and facial aesthetic surgery.

It is vital that clear airway management plans including rescue plans are made at the outset. These must be communicated to the surgical and anaesthetic team in advance. Trauma is excluded as it will be covered in a separate review article.

Full reference: Kersan, L. & Ratnasabapathy, U. (2017) Anaesthesia for maxillofacial surgery. Anaesthesia and Intensive Care Medicine. Published online: 29 July 2017

The Role of Science in Addressing the Opioid Crisis

Opioid misuse and addiction is an ongoing and rapidly evolving public health crisis, requiring innovative scientific solutions | New England Journal of Medicine

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Image source: Marina Caruso – Wellcome Images // CC BY-NC-ND 4.0

In response, and because no existing medication is ideal for every patient, the National Institutes of Health (NIH) is joining with private partners to launch an initiative in three scientific areas: developing better overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery; finding new, innovative medications and technologies to treat opioid addiction; and finding safe, effective, nonaddictive interventions to manage chronic pain. Each of these areas requires a range of short-, intermediate-, and long-term research strategies

Full reference: Volkow, N.D. & and Collins, F.S. (2017) The Role of Science in Addressing the Opioid Crisis.  New England Journal of Medicine. Issue 377: pp.391-394

Interventions for Neuropathic Pain: An Overview of Systematic Reviews

Numerous interventions for neuropathic pain (NeuP) are available, but its treatment remains unsatisfactory | Anesthesia & Analgesia

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We systematically summarized evidence from systematic reviews (SRs) of randomized controlled trials on interventions for NeuP. Five electronic databases were searched up to March 2015. Study quality was analyzed using A Measurement Tool to Assess Systematic Reviews.

The most common interventions in 97 included SRs were pharmacologic (59%) and surgical (15%). The majority of analyzed SRs were of medium quality. More than 50% of conclusions from abstracts on efficacy and approximately 80% on safety were inconclusive.

Effective interventions were described for painful diabetic neuropathy (pregabalin, gabapentin, certain tricyclic antidepressants [TCAs], opioids, antidepressants, and anticonvulsants), postherpetic neuralgia (gabapentin, pregabalin, certain TCAs, antidepressants and anticonvulsants, opioids, sodium valproate, topical capsaicin, and lidocaine), lumbar radicular pain (epidural corticosteroids, repetitive transcranial magnetic stimulation [rTMS], and discectomy), cervical radicular pain (rTMS), carpal tunnel syndrome (carpal tunnel release), cubital tunnel syndrome (simple decompression and ulnar nerve transposition), trigeminal neuralgia (carbamazepine, lamotrigine, and pimozide for refractory cases, rTMS), HIV-related neuropathy (topical capsaicin), and central NeuP (certain TCAs, pregabalin, cannabinoids, and rTMS).

Evidence about interventions for NeuP is frequently inconclusive or completely lacking. New randomized controlled trials about interventions for NeuP are necessary; they should address safety and use clear diagnostic criteria.

Full reference: Dosenovic, S. et al. (2017) Interventions for Neuropathic Pain: An Overview of Systematic Reviews. Anesthesia & Analgesia. Vol. 125 (Issue 2) pp. 643–652

Principles of Burn Pain Management

This article describes pathophysiology of burn injury–related pain and the basic principles of burn pain management | Clinics in Plastic Surgery

The focus is on concepts of perioperative and periprocedural pain management with extensive discussion of opioid-based analgesia, including patient-controlled analgesia, challenges of effective opioid therapy in opioid-tolerant patients, and opioid-induced hyperalgesia. The principles of multimodal pain management are discussed, including the importance of psychological counseling, perioperative interventional pain procedures, and alternative pain management options. A brief synopsis of the principles of outpatient pain management is provided.

Full reference: James, D.L. & Jowza, M. (2017) Principles of Burn Pain Management. Clinics in Plastic Surgery. Published online: 15 July 2017

Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery

Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy | Anesthesia & Analgesia

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Background: Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor.

Conclusions: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation.

Full reference: Kantor, E. et al. (2017) Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery: A French Retrospective, Multicenter, Cohort Study. Anesthesia & Analgesia. Post Author Corrections: 13 July 2017