Current and Emerging Anesthesia Technology in 2016

Gálvez, J.A. et al. Anesthesiology News. Published online: October 27 2016

B0007020 Science research

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

This review focuses on emerging technological developments in anesthesiology that are available in the United States and around the world. Much of this review comes from content presented at the 2016 annual meeting of the Society for Technology in Anesthesia (STA), which can be accessed online at www.stahq.org.

Innovations are included in the areas of:

  • Closed-Loop Systems
  • Quality Measurement and Health Information Exchange
  • Anesthesia Machines
  • Carbon Dioxide Absorber
  • Physiologic Monitors
  • Capnographic Analysis
  • Surgical Blood Loss Monitoring
  • Anesthesia Information Management and Clinical Decision Support Systems
  • Simulation

Read the full article here

 

Improved decision support in the assessment and management of pain for people with dementia in hospital

Closs, S.J. et al. NIHR. Published online: October 2016

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It is difficult for people with dementia to communicate their pain to health-care professionals. Pain often has damaging effects on mental and physical health, and research has shown that pain is often poorly managed in people with dementia in hospital.

We aimed to develop a new system that would help staff to manage pain. To this end, we first identified any accurate and reliable pain assessment tools available for use with hospital patients who have dementia. We then explored how pain is currently recognised, assessed and managed in people with dementia in four hospitals in England and Scotland.

We found 28 pain assessment tools which had been reviewed, but none had been tested rigorously. Seven had potentially useful features, but no single tool could be recommended for wider use. The 11 hospital wards studied were all different, with their own complex pain assessment and management practices. Information from different staff and carers was produced at different times and in different formats, and was recorded in separate documents. This information was mentally pulled together into an ‘overall picture’ of pain by each staff member for each individual patient.

We suggest developing a combined education package and electronic health record, the Pain And Dementia Decision Support (PADDS) intervention, to help staff recognise, assess and manage pain. This should incorporate carer input, staff narratives, pain histories, intensity assessments, medication and other interventions provided, and present an overall picture of pain in an integrated and easily accessible visual format. This will require thorough development and testing.

Read the full report here

Young children’s ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective

Jaaniste, T. et al. (2016) Pain. 157(11). pp. 2399–2409

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Children are at times asked by clinicians or researchers to rate their pain associated with their past, future, or hypothetical experiences. However, little consideration is typically given to the cognitive-developmental requirements of such pain reports. Consequently, these pain assessment tasks may exceed the abilities of some children, potentially resulting in biased or random responses. This could lead to the over- or under-treatment of children’s pain.

This review provides an overview of factors, and specifically the cognitive-developmental prerequisites, that may affect a child’s ability to report on nonpresent pain states, such as past, future, or hypothetical pain experiences. Children’s ability to report on past pains may be influenced by developmental (age, cognitive ability), contextual (mood state, language used by significant others), affective and pain-related factors.

The ability to mentally construct and report on future painful experiences may be shaped by memory of past experiences, information provision and learning, contextual factors, knowledge about oneself, cognitive coping style, and cognitive development. Hypothetical pain reports are sometimes used in the development and validation of pain assessment scales, as a tool in assessing cognitive-developmental and social-developmental aspects of children’s reports of pain, and for the purposes of training children to use self-report scales. Rating pain associated with hypothetical pain scenarios requires the ability to recognize pain in another person and depends on the child’s experience with pain.

Enhanced understanding of cognitive-developmental requirements of young children’s pain reports could lead to improved understanding, assessment, and treatment of pediatric pain.

Read the abstract here

Chronic Pain Management: Moving Beyond Pharmacotherapy

Heale, R. Evidence-Based Nursing Blog. Published online: 23 October 2016

B0005910 Back pain

Image source: Bill McConkey – Wellcome Images // CC BY-NC-ND 4.0

Pain is an essential part of life.  It tells us when and where we’ve sustained an injury.  This acute pain ensures that we seek out and address the problem at hand.  However, some pain continues for much longer than necessary. Pain signals remain active, muscles tense in response, energy is lowered and there are changes in appetite.  People often experience depression, anxiety or anger as a result of living with these ongoing effects.

Treatment of chronic pain can be complex. There are a whole host of medications ranging from opioids to antidepressants to medications addressing neuropathic pain.  Although useful in many cases, medications are not without side effects and there can be negative outcomes, including addiction.  More and more we see alternative therapies being implemented to help in the management of chronic pain such as yoga, massage and acupuncture.  In recent years, attention has turned to treatments that address mental and psychological coping of patients, such as cognitive behavioural therapy (CBT).

Read the full blog post here

Peripheral nerve blocks in the management of postoperative pain: challenges and opportunities

Joshi, G. (2016) Journal of Clinical Anesthesia. 35, pp. 524–529

Highlights

  • Peripheral nerve block (PNB) improves pain control and reduces opioid requirements compared with opioids alone.
  • Continuous PNB prolongs analgesia but introduces significant risks and challenges.
  • The ideal PNB technique would have a sufficient duration of action and minimal risk of complications.

Abstract

Peripheral nerve blocks (PNBs) are increasingly used as a component of multimodal analgesia and may be administered as a single injection (sPNB) or continuous infusion via a perineural catheter (cPNB). We undertook a qualitative review focusing on sPNB and cPNB with regard to benefits, risks, and opportunities for optimizing patient care. Meta-analyses of randomized controlled trials have shown superior pain control and reductions in opioid consumption in patients receiving PNB compared with those receiving intravenous opioids in a variety of upper and lower extremity surgical procedures. cPNB has also been associated with a reduction in time to discharge readiness compared with sPNB. Risks of PNB, regardless of technique or block location, include vascular puncture and bleeding, nerve damage, and local anesthetic systemic toxicity. Site-specific complications include quadriceps weakness in patients receiving femoral nerve block, and pleural puncture or neuraxial blockade in patients receiving interscalene block. The major limitation of sPNB is the short (12-24 hours) duration of action. cPNB may be complicated by catheter obstruction, migration, and leakage of local anesthetic as well as accidental removal of catheters. Potential infectious complications of catheters, although rare, include local inflammation and infection. Other considerations for ambulatory cPNB include appropriate patient selection, education, and need for 24/7 availability of a health care provider to address any complications. The ideal PNB technique would have a duration of action that is sufficiently long to address the most intense period of postsurgical pain; should be associated with minimal risk of infection, neurologic complications, bleeding, and local anesthetic systemic toxicity; and should be easy to perform, convenient for patients, and easy to manage in the postoperative period.

View the full article here

Fragmented Sleep Enhances Postoperative Neuroinflammation but Not Cognitive Dysfunction.

Vacas, S. et al. Anesthesia & Analgesia. Published online: October 11 2016

https://wellcomeimages.org/indexplus/result.html?_IXMAXHITS_=1&_IXACTION_=query&_IXFIRST_=5&_IXSR_=jvX_O7phSMA&_IXSS_=_IXMAXHITS_%3d15%26_IXFPFX_%3dtemplates%252ft%26_IXFIRST_%3d1%26c%3d%2522historical%2bimages%2522%2bOR%2b%2522contemporary%2bimages%2522%2bOR%2b%2522corporate%2bimages%2522%2bOR%2b%2522contemporary%2bclinical%2bimages%2522%26%252asform%3dwellcome%252dimages%26%2524%253dsi%3dtext%26_IXACTION_%3dquery%26i_pre%3d%26IXTO%3d%26t%3d%26_IXINITSR_%3dy%26i_num%3d%26%2524%253dsort%3dsort%2bsortexpr%2bimage_sort%26w%3d%26%2524%253ds%3dsleep%2bdigital%26IXFROM%3d%26_IXSUBMIT_%3dSubmit%26_IXshc%3dy%26%2524%2b%2528%2528with%2bwi_sfgu%2bis%2bY%2529%2band%2bnot%2b%2528%2522contemporary%2bclinical%2bimages%2522%2bindex%2bwi_collection%2bor%2b%2522corporate%2bimages%2522%2bindex%2bwi_collection%2529%2529%2band%2bnot%2bwith%2bsys_deleted%3d%252e%26_IXrescount%3d8&_IXSPFX_=templates%2ft&_IXFPFX_=templates%2ft

Image source: Tim Ellis – Wellcome Images // CC BY-NC-ND 4.0

Background: Sleep is integral to biologic function, and sleep disruption can result in both physiological and psychologic dysfunction including cognitive decline. Surgery activates the innate immune system, inducing neuroinflammatory changes that interfere with cognition. Because surgical patients with sleep disorders have an increased likelihood of exhibiting postoperative delirium, an acute form of cognitive decline, we investigated the contribution of perioperative sleep fragmentation (SF) to the neuroinflammatory and cognitive responses of surgery.

Methods: The effects of 24-hour SF and surgery were explored in adult C57BL/6J male mice. The SF procedure started at 7 AM with cages being placed on a large platform orbital shaker that cycled every 120 seconds (30 seconds on/90 seconds off) for 24 hours. In separate cohorts, stabilized tibial fracture was performed either before or after the 24-hour SF procedure and assessed for systemic and hippocampal inflammation and cognition.

Results: SF-induced nonhippocampal memory dysfunction (mean +/- standard deviation [SD] of the difference in time spent between novel and familiar object for control was 4.7 +/- 1.4 seconds, n = 8 versus SF -0.5 +/- 0.2 seconds, n = 11, yielding an estimated treatment effect of 5.2 seconds [95% confidence interval {CI}, 2.6-7.7]; P < .001) and increased systemic interleukin-6 (median [25%-75% quartile] for control 0.0 [0.0-2.4] pg/mL versus 9.7 [6.3-12.9] pg/mL, n = 8/group, yielding an estimated treatment effect of 9.7 pg/mL [95% CI, 5.8-11.8]; P < .0001). SF reduced freezing time in hippocampal-dependent memory test (mean +/- SD for control 49.3% +/- 5.8% versus for SF 32.9% +/- 5.8%, n = 10/group, estimated treatment effect = 16.4% [95% CI, 11.0-21.8]; P < .0001). Although surgery also reduced freezing time (mean +/- SD for control 49.3% +/- 5.8% versus for surgery 30.3% +/- 3.3%, n = 10/group, estimated treatment effect = 19.0% [95% CI, 14.6-23.4]; P < .0001), memory impairment was not further exacerbated by combining SF with surgery. One day after SF, there was an increase in hippocampal messenger RNA expression of tumor necrosis factor-[alpha] (relative quantitation [RQ] 5.12-fold, n = 5/group [95% CI, 1.64-15.97]; P < .01), and 1 day after surgery, there was an increase in messenger RNA interleukin-6 (RQ 4.64-fold, n = 5 [95% CI, 1.48-14.56]; P < .05) and tumor necrosis factor-[alpha] (RQ 5.54-fold, n = 5 [95% CI, 2.92-10.51]; P < .01). These increments were more pronounced when either pre- or postoperative SF was combined with surgery.

Conclusions: Although SF and surgery can independently produce significant memory impairment, perioperative SF significantly increased hippocampal inflammation without further cognitive impairment. The dissociation between neuroinflammation and cognitive decline may relate to the use of a sole memory paradigm that does not capture other aspects of cognition, especially learning.

Read the abstract here