Regional anesthesia and analgesia after surgery in ICU

The aim is to demonstrate that ICU physicians should play a pivotal role in developing regional anesthesia techniques that are underused in critically ill patients despite the proven facts in perioperative and long-term pain, organ dysfunction, and postsurgery patient health-related quality of life improvement | Current Opinion in Critical Care

Regional anesthesia and/or analgesia strategies in ICU reduce the surgical and trauma–stress response in surgical patients as well as complications incidence. Recent studies suggested that surgical/trauma ICU patients receive opioid–hypnotics continuous infusions to prevent pain and agitation that could increase the risk of posttraumatic stress disorder and chronic neuropathic pain symptoms, and chronic opioid use. Regional anesthesia use decrease the use of intravenous opioids and the ectopic activity of injured small fibers limiting those phenomena. In Cochrane reviews and prospective randomized trials in major surgery patients, regional anesthesia accelerates the return of the gastrointestinal transit and rehabilitation, decreases postoperative pain and opioids use, reduces ICU/hospital stay, improves pulmonary outcomes, including long period of mechanical ventilation and early extubation, reduces overall adverse cardiac events, and reduces ICU admissions when compared with general anesthesia and intravenous opiates alone. The reduction of long-term mortality has been reported in major vascular or orthopedic surgeries.

Promoting regional anesthesia/analgesia in ICU surgical/trauma patients could undoubtedly limit the risk of complications, ICU/hospital stay, and improve patient’s outcome. The use of regional anesthesia permits a high doses opioid use limitation which is mandatory and should be considered as feasible and well tolerated in ICU.

Full reference: Capdevila, M. et al. (2017) Regional anesthesia and analgesia after surgery in ICU. Current Opinion in Critical Care. Vol. 23 (Issue 5) pp. 430–439

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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

Referral From One Surgeon to Another to Reduce Maximum Waiting Time

Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients’ understanding of treatment options | Anesthesia & Analgesia

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Background: We consider shared decision making applied to case scheduling, since implementation would reduce labor costs.

Methods: Study questions were presented in sequence of waiting times, starting with 4 workdays. “Assume the consultant surgeon (ie, the surgeon in charge) you met in clinic did not have time available to do your surgery within the next 4 workdays, but his/her colleague would have had time to do your surgery within the next 4 workdays. Would you have wanted to discuss with a member of the surgical team (eg, the scheduler or the surgeon) the availability of surgery with a different, equally qualified surgeon at Mayo Clinic who had time available within the next 4 workdays, on a date of your choosing?” There were 980 invited patients who underwent lung resection or cholecystectomy between 2011 and 2016; 135 respondents completed the study and 6 respondents dropped out after the study questions were displayed.

Results: The percentages of patients whose response to the study questions was “4 days” were 58.8% (40/68) among lung resection patients and 58.2% (39/67) among cholecystectomy patients. The 97.5% 2-sided confidence interval for the median maximum wait was 4 days to 4 days. Patients’ choices for the waiting time sufficient to discuss having another surgeon perform the procedure did not differ between procedures (P = .91). Results were insensitive to patients’ sex, age, travel time to hospital, or number of office visits before surgery (all P >= .20).

Conclusion: Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients’ individual preferences (ie, patient-centered).

Full reference: Logvinov, I. I. et al. (2017) Patient Survey of Referral From One Surgeon to Another to Reduce Maximum Waiting Time for Elective Surgery and Hours of Overutilized Operating Room Time. Anesthesia & Analgesia: Post Author Corrections: July 10, 2017