Acute Ischemic Pain Research Articles

PHLEGMASIA CERULEA DOLENS ASSOCIATED WITH OBSTRUCTIVE SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare, fulminant condition caused by massive venous thrombosis associated with a high morbidity (amputation rates 20-50%) and mortality (25-40%)1. PCD often presents as a triad of limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration1. This case presents a patient who developed PCD involving complete obstruction of the inferior vena cava (IVC) leading to obstructive shock. CASE PRESENTATION: Shortly after admission a 67 year old female with a relevant past medical history of metastatic tonsillar cancer on chemotherapy, Sjogren's disease, and previous venous thromboembolism (no longer on anticoagulation) developed acute onset of abdominal pain and hypotension associated with significant mottling and edema in her bilateral lower extremities. Six months prior to presentation she had an IVC filter placed. She developed worsening shock, acute kidney injury, and metabolic academia. A CT abdomen/pelvis revealed an extensive clot burden distal to the IVC filter with extension down through the bilateral iliac veins (img 1). Bilateral lower extremity venous duplex ultrasound scans showed extensive bilateral acute deep vein thromboses (img 2). Vascular surgery took the patient to the operating room for mechanical thrombectomy of the IVC and left iliac vein (img 3) and right above-the-knee amputation due to the severity of injury to right lower extremity. After returning from the operating room she developed worsening shock despite continued resuscitative measures, and after discussion with the patient's family her goals of care were transitioned to comfort-focused. DISCUSSION: Similar to DVT risk, factors associated with the development of PCD include congestive heart failure, immobility post-operatively, and malignancy1,2. Chemotherapy may increase the risk by up to six to seven times3. Initial management of PCD includes elevation of affected limbs, judicious fluid resuscitation, and anticoagulation1. Definitive therapeutic interventions include catheter-directed thrombolysis and surgical thrombectomy1. IVC filter presence is also a rare but important risk factor for the development of PCD associated with up to 3.2% of cases in one review1. The presence of an IVC filter may lead to the development of inferior vena cava syndrome which is often mistaken for other conditions. Complications associated with IVC filter presence also highlights the value of bedside ultrasound which could help to identify non-collapsible femoral veins. CONCLUSIONS: The clinical triad of PCD includes limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration. Early recognition and treatment is critical to improved outcomes.Risk factors for the development of PCD are the same as those associated with DVT or PE IVC filter presence can be a nidus for thrombus development which can progress to the point of filter occlusion REFERENCE #1: Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. doi:10.1177/1538574410388309 REFERENCE #2: Mohammed, M., Elhamdani, S., Abusnina, W., Majdi, A., & Yousef, S. (2018). Inferior Vena Cava Obstruction and Shock. Journal of emergencies, trauma, and shock, 11(2), 146–148. https://doi.org/10.4103/JETS.JETS_22_17 REFERENCE #3: Söderman, M., & Grimm, P. (2020). Phlegmasia cerulea dolens in a patient treated with carboplatin. BMJ case reports, 13(4), e233760. https://doi.org/10.1136/bcr-2019-233760 DISCLOSURES: No relevant relationships by Avraham Cooper, source=Web Response No relevant relationships by Sarah MacDowell, source=Web Response

Organoprotection in patients with COVID-19

Background. Treatment of chronic coronary syndrome (CCS) includes the elimination of acute ischemic pain, prevention of ischemic pain, symptomatic treatment, and influence on the prognosis. The health of patients with CCS during their lifetime is affected by the diet, climate, medication, exposure to toxic substances, and now the COVID-19 epidemic.
 Objective. To describe the available options of cardioprotection and metabolic therapy.
 Materials and methods. Analysis of literature data on this topic and own research “Smart ECG”.
 Results and discussion. A significant number of the foreign scientists’ papers have been devoted to the problems of the excessive release of free radicals, mitochondrial DNA damage, reduction of ATP content and cardiocytoprotection. Even the short-term ischemia depletes ATP depots and slows their recovery. Metabolic therapy is able to protect cardiomyocytes from the hypoxic death due to the mismatch of energy production by mitochondria to the energy needs of the cell. According to the results of the own study “Smart ECG”, L-arginine and L-carnitine (Tivorel, “Yuria-Pharm”) activates parasympathetic regulation in stable angina, reducing the risk of adverse events. Vascular, immunomodulatory, antioxidant and cytoprotective properties of L-carnitine and L-arginine make their use reasonable for COVID-19.
 Conclusions. 1. Metabolic therapy is an important component of the treatment of CCS. 2. L-carnitine and L-arginine have the pronounced vascular, immunomodulatory, antioxidant and cytoprotective properties. 3. It is reasonable to use these drugs during an epidemic of COVID-19.

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

A Blue Leg: An Interventional Approach to a Limb-Threatening Deep Vein Thrombosis

Fentanyl Buccal Tablet: A New Breakthrough Pain Medication in Early Management of Severe Vaso-Occlusive Crisis in Sickle Cell Disease.

Sickle cell disease (SCD) is a worldwide distributed hereditary red cell disorder. The principal clinical manifestations of SCD are the chronic hemolytic anemia and the acute vaso-occlusive crisis (VOCs), which are mainly characterized by ischemic/reperfusion tissue injury. Pain is the main symptom of VOCs, and its management is still a challenge for hematologists, requiring a multidisciplinary approach. We carried out a crossover study on adult SCD patients, who received two different types of multimodal analgesia during two separate severe VOCs with time interval between VOCs of at least 6months. The first VOC episode was treated with ketorolac (0.86mg/kg/day) and tramadol (7.2mg/kg/day) (TK treatment). In the second VOC episode, fentanyl buccal tablet (FBT; 100μg) was introduced in a single dose after three hours from the beginning of TK analgesia (TKF treatment). We focused on the first 24hours of acute pain management. The primary efficacy measure was the time-weighted-sum of pain intensity differences (SPID24). The secondary efficacy measures included the pain intensity difference (PID), the total pain relief (TOTPAR), and the time-wighted sum of anxiety (SAID24). SPID24 was significantly higher in TKF than in TK treatment. All the secondary measures were significantly ameliorated in TKF compared to TK treatment, without major opioid side effects. Patients satisfaction was higher with TKF treatment than with TK one. We propose that VOCs might require breakthrough pain drug strategy as vaso-occlusive phenomena and enhanced vasoconstriction promoting acute ischemic pain component exacerbate the continuous pain of VOCs. FBT might be a powerful and feasible tool in early management of acute pain during VOCs in emergency departments.

Investigating a Model for Acute Ischemic Pain in Humans

Background: The pathophysiology of acute ischemic pain is not well established. The aim of the present study was to investigate acute ischemic pain in humans with a view to establish a scientific model to perform future studies. We examined whether peripheral nerve damage and acute inflammation occur during short episodes of acute ischemia. Methods: Eleven patients with unilateral peripheral arterial disease (PAD) performed treadmill exercise until intolerable ischemic pain urged them to stop. Blood samples were taken before, immediately after treadmill exercise and after a period of recovery. S100B-serum was detected via Elecsys® S100B Immunoassay and IL-6 levels determined via COBAS® IL6 Elecsys 2010. Results: Treadmill exercise led to intolerable exercise-induced ischemic pain (Numeric Rating Scale) 9 ± 0.3 (0- 10, mean ± SEM)) in the PAD affected leg. Reduced ankle/brachial-index (ABI) (0.13 ± 0.05 mean ± SEM) with a mean ankle pressure of 26 ± 9 mmHg, pO2, pH and increased serum lactate indicated that severe ischemia occurred in the PAD affected leg. The inflammation marker IL-6 increased locally and systemically post exercise (n.s.). Conclusion: We present an effective method to examine acute ischemic pain in humans. By focusing on changes in metabolic parameters in the affected limb, this model could potentially help to evaluate and detect changes during acute ischemic pain and thus contribute to the understanding of the underlying pathophysiology.

Beneficial effect of intravenous nitroglycerin and lidocaine in severe pain due to acute arterial occlusion

This is a case report of a patient (man, 65 year, 70 kg) with severe abdominal and lower extremity pain. Diagnostic methods including color Doppler ultrasound, computed tomography (CT) with contrast, and CT angiography showed thrombosis in abdominal artery near bifurcation of superior mesenteric artery. His pain did not respond to abdominal thromboembolectomy and intravenous injection of heparin and then opioid and acetaminophen. After continuous infusion of lidocaine and nitroglycerin, pain decrease about 20% and after 48 h, it decreases to 80%. This method may be a good option for pain management of acute ischemic pain due to acute arterial occlusion.

Ruptured aortic aneurysm masquerading as phlegmasia cerulea

Phlegmasia cerulea dolens, characterized by the triad of limb swelling, cyanosis, and acute ischemic pain, usually arises because of acute massive thrombosis of major deep, collateral, and superficial veins of an extremity. We report a patient with an atypically presenting ruptured aortic aneurysm masquerading as phlegmasia cerulea dolens. A 68-year-old man with a history of hypertension, intermittent claudication, and smoking presented with asthenia, macrohematuria, and mild back pain, as well as edema and blue mottling of the lower limbs and abdomen for 24 hours. The abdomen was nontender without a pulsatile mass or murmur. Computed tomography showed an 85-mm abdominal aortic aneurysm ruptured into the inferior vena cava. Phlegmasia cerulea dolens-like symptoms were explained by compromised venous outflow from the lower limbs because of an aortocaval fistula. The patient died of uncontrollable hemorrhage during emergent surgical repair. Three percent to 6% of patients with abdominal aortic aneurysm rupture present an aortocaval fistula, which can be suspected by the triad of abdominal or lower back pain, pulsatile abdominal mass, and machinery-type abdominal murmur. Left untreated, this condition rapidly leads to death from congestive heart failure. Only one third of patients are diagnosed before surgery because a fistula is often not suspected until unexplained massive hemorrhage occurs during the operation. Operative mortality is extremely high (34%). We propose that the clinical syndrome presented by our patient, a "blue fistula" frequently associated with aortocaval fistulae, be called phlegmasia cerulea non dolens, by analogy to Grégoire's "blue phlebitis."

Parental history of chronic pain may be associated with impairments in endogenous opioid analgesic systems

A family history of chronic pain has previously been linked to increased incidence of spontaneous acute pain and risk for chronic pain. Mechanisms underlying these associations are unknown, although similar effects on both acute and chronic pain suggest that central endogenous analgesic system differences may be relevant. This study tested whether a positive parental chronic pain history (PH+) was associated with impaired endogenous opioid analgesic responses to acute pain. Seventy-three chronic low back pain patients (LBP) and 46 pain-free controls received opioid blockade (8 mg naloxone i.v.) and placebo blockade (saline) in randomized, counterbalanced order in separate sessions. During each, subjects participated in a 1-min finger pressure pain task followed by an ischemic forearm pain task, providing pain intensity ratings during and immediately following each task. To assess opioid analgesic function, blockade effects were derived by subtracting placebo from blockade condition pain responses. Placebo condition analyses indicated that both PH+ subjects and LBP subjects reported greater acute pain sensitivity than respective comparison groups ( p’s < .05). Multivariate analyses indicated that, beyond any influence of current chronic pain status, PH+ subjects failed to exhibit any endogenous opioid analgesia to acute ischemic pain, whereas PH− subjects elicited effective opioid analgesia ( p < .05). A significant multivariate PH × Subject Type interaction ( p < .05) indicated that opioid analgesic impairments were most prominent in PH+ LBP subjects. Similar analyses for finger pressure pain blockade effects were nonsignificant ( p > .10). The possible heritability of endogenous opioid analgesic dysfunction observed in individuals with a positive parental chronic pain history remains to be investigated.

Influence of electrocardiographic findings on admission decisions in patients with acute chest pain

This study prospectively evaluated the influence of current electrocardiograms obtained at the time of emergency department presentation, as well as that of previous comparison electrocardiograms, on decision-making regarding coronary care unit admission of patients presenting with a chief complaint of chest pain or chest pain equivalent. Emergency department physicians were asked to commit themselves to recommending either coronary care unit admission or some other disposition, both before and after evaluating current comparison electrocardiographic findings. They were also asked, prior to reviewing these results, whether they thought information gained from the electrocardiograms would have any affect on their decision. Despite wide expectation that electrocardiographic findings would in fact affect decision-making, neither current nor comparison electrocardiograms virtually ever altered the ultimate decision of whether or not to admit. Faculty and house officers performed similarly in all regards, except insofar as attending physicians were less likely to expect electrocardiographic findings to help them in patients who were ultimately discharged. Emergency department nurses, who were asked whether they believed these patients needed admission to a coronary care unit on the basis of only a brief initial triage history, performed very similarly to the physicians. Thus, electrocardiographic findings are rarely if ever helpful in determining the need for admission to a coronary care unit in patients presenting to the emergency department with chest pain, and seem to have particularly little value in patients in whom myocardial infarction is considered clinically unlikely. Although physicians at all levels of training often feel a need to rely on electrocardiograms in patients they ultimately admit, greater experience allows more senior physicians to be comfortable in correctly discharging patients with no clinical evidence of disease without obtaining an electrocardiogram. Routine ordering of electrocardiograms in patients with chest pain in whom likelihood of significant acute ischemic pain is clinically low should be reconsidered.

Nitrate Therapy for Angina Pectoris

• Nitrates are presently used in the therapy for angina pectoris. They have both direct coronary vascular and indirect systemic effects; each appears to contribute to their antianginal efficacy. The various nitrate preparations, including the newer preparations recently made clinically available, have varying utilities in the relief of acute ischemic pain or for anginal prophylaxis. Nitrate tolerance and dependence are proved phenomena, yet their impact on the clinical usage of nitrates is not clearly defined. The utility of nitrates, including intravenous nitroglycerin, in the treatment of unstable angina and vasospastic angina is well documented. Their efficacy compared with that of calcium channel blockers is still being investigated. The reported adverse effects of nitrates are few, despite their many years of usage in clinical medicine. (Arch Intern Med1985;145:538-543)

Nitrate therapy for angina pectoris. Current concepts about mechanism of action and evaluation of currently available preparations.

Nitrates are presently used in the therapy for angina pectoris. They have both direct coronary vascular and indirect systemic effects; each appears to contribute to their anti-anginal efficacy. The various nitrate preparations, including the newer preparations recently made clinically available, have varying utilities in the relief of acute ischemic pain or for anginal prophylaxis. Nitrate tolerance and dependence are proved phenomena, yet their impact on the clinical usage of nitrates is not clearly defined. The utility of nitrates, including intravenous nitroglycerin, in the treatment of unstable angina and vasospastic angina is well documented. Their efficacy compared with that of calcium channel blockers is still being investigated. The reported adverse effects of nitrates are few, despite their many years of usage in clinical medicine.

Relaxation training and cognitive redirection strategies in the treatment of acute pain

Relaxation training, relaxation instructions, and redirection of attention techniques were compared to a no-treatment control in the treatment of acute ischemic pain. Relaxation instructions were ineffective in reducing state anxiety, verbally reported pain or distress or pain measured during presentation of the stimulus by cross-modality matching. Relaxation training was effective in reducing distress during presentation of the stimulus and verbally reported pain. The attention-redirection technique reduced pain as measured by cross-modality matching. The interaction hypothesis was supported, re. the two measures of distress during presentation of the painful stimulus. As externality increased, the effectiveness of relaxation training increased. However, there was no consistent decrease in distress for subjects high on externality in the relaxation instruction group.