Acute Pain Medicine Research Articles

Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management.

Patient education materials (PEM) should be written at a sixth-grade reading level or lower. We evaluated the availability and readability of online PEM related to regional anesthesia and compared the readability and content of online PEM produced by fellowship and nonfellowship institutions. With IRB exemption, we constructed a cohort of online regional anesthesia PEM by searching Websites from North American academic medical centers supporting a regional anesthesiology and acute pain medicine fellowships and used a standardized Internet search engine protocol to identify additional nonfellowship Websites with regional anesthesia PEM based on relevant keywords. Readability metrics were calculated from PEM using the TextStat 0.1.4 textual analysis package for Python 2.7 and compared between institutions with and without a fellowship program. The presence of specific descriptive PEM elements related to regional anesthesia was also compared between groups. PEM from 17 fellowship and 15 nonfellowship institutions were included in analyses. The mean (SD) Flesch-Kincaid Grade Level for PEM from the fellowship group was 13.8 (2.9) vs 10.8 (2.0) for the nonfellowship group (p = 0.002). We observed no other differences in readability metrics between fellowship and nonfellowship institutions. Fellowship-based PEM less commonly included descriptions of the following risks: local anesthetic systemic toxicity (p = 0.033) and injury due to an insensate extremity (p = 0.003). Available online PEM related to regional anesthesia are well above the recommended reading level. Further, fellowship-based PEM posted are at a higher reading level than PEM posted by nonfellowship institutions and are more likely to omit certain risk descriptions.

(402) A retrospective investigation into the impact of early post-operative intravenous ketamine infusion on recovery and phantom limb pain in new amputees

NMDA receptor antagonists, such as ketamine, have been purported to minimize central sensitization at the spinal cord level and may decrease ongoing neuropathic pain following acute neuronal injury. There is conflicting information in the literature regarding the efficacy of intravenous ketamine infusions to treat acute post-amputation pain and potentially ameliorate chronic phantom limb pain. This retrospective observational study tests the hypothesis that intravenous ketamine infusions initiated within 30 days of limb amputation will improve phantom pain sensations, pain at discharge, decrease concurrent opioid usage, and contribute to better outcomes without significant adverse effects. All patients that underwent limb amputation and received a consult to the Acute Pain Medicine Service (APMS) for ketamine treatment during hospitalization from January 2009 through October 2015 are eligible for study inclusion. IRB approved data collection includes APMS documentation of pain characterization and intensity over time, pain at discharge, duration and dosage of ketamine, adjuvant analgesic usage, co-morbidities, and psychoactive, hepatic, or cardiovascular side effect occurrences. Data collection is ongoing and currently inconclusive, however there is a trend towards decreased neuropathic pain and phantom sensations at doses with a minimal side effect profile. The patient population referred to APMS is likely biased by greater uncontrolled pain, potentially in conjunction with more complex comorbidities limiting medication management. Therapeutic significance in this challenging population suggests beneficial application to a broader spectrum of patients undergoing amputation. In conclusion, our preliminary findings on the safety and efficacy of ketamine infusion for phantom pain during the initial post-amputation hospitalization warrants further prospective research to investigate its potential role in acute pain management protocols.

Acute pain services in India: A long and challenging journey ahead

Acute post-operative pain and other forms of pain are widely undertreated globally including the Indian hospitals. As a result a large proportion of patients suffer from moderate to severe forms of pain. Undertreated pain can have many negative consequences such as pulmonary complications, acute myocardial ischemic events, delayed wound healing, prolonged hospital stay, etc. In spite of this acute pain continues to be negelected. The solution to poorly managed pain is not just developing newer and sophisticated techniques. But the solution lies in developing a dedicated, round-the-clock service called as acute pain service. This concept has gained world wide acceptance in last two decades and a majority of countries are developing such pain services in the hospitals. Unfortunately in India the field of acute pain medicine is still in its infancy. A very few hospitals have full fledged Acute Pain Services. In this review article we have tried to throw light on the hurdles in developing Acute Pain Services in our country. Also we have suggested a few possible solutions.

Spring 2016 Abstract Titles

Spring 2016 Abstract Titles

The Effect of Palliative Care Team Design on Referrals to Pediatric Palliative Care.

The American Academy of Pediatrics (AAP) and the American Academy of Hospice and Palliative Medicine (AAHPM) have recommended minimal standards for palliative care (PC) team composition and availability. It is unknown whether team composition affects utilization of PC. The study objective was to describe pediatric PC team composition, evaluate whether composition and availability are associated with utilization, and examine PC referral patterns. The study was a descriptive survey. Subjects were pediatric PC team directors or hospital administrators at Pediatric Health Information System (PHIS) hospitals (N = 44). The overall response rate was 86%. Teams varied in size from <1 to 9 full-time members. Average referrals per hospital bed were 0.46, range 0.05-2.13. Among individual PC team roles, referral rates were 34% greater in teams with an advanced nurse practitioner (ANP) (p = 0.07). Likewise, teams with acute pain, chronic pain, or hospice palliative medicine specialists tended to have greater referral rates (39%, 36%, and 25%), though reported differences were not statistically significant. Teams adherent to the original AAP recommendations had a 31% greater referral rate (p = 0.22). Teams available 24 hours daily had similar referral rates to those with less availability (0.47 versus 0.46 [p = 0.94]). Team composition and availability are not crucial to PC utilization. Hospitals with some personnel but not all recommended team members should create formal teams and modify them over time. The addition of team members that tend to increase referrals, namely ANPs and acute pain, chronic pain, or hospice palliative medicine specialists, should be considered.

Acute Pain Medicine in the United States: A Status Report.

Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs. A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education. The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM. This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

Simulation in teaching regional anesthesia: current perspectives.

The emerging subspecialty of regional anesthesiology and acute pain medicine represents an opportunity to evaluate critically the current methods of teaching regional anesthesia techniques and the practice of acute pain medicine. To date, there have been a wide variety of simulation applications in this field, and efficacy has largely been assumed. However, a thorough review of the literature reveals that effective teaching strategies, including simulation, in regional anesthesiology and acute pain medicine are not established completely yet. Future research should be directed toward comparative-effectiveness of simulation versus other accepted teaching methods, exploring the combination of procedural training with realistic clinical scenarios, and the application of simulation-based teaching curricula to a wider range of learner, from the student to the practicing physician.

Continuous Versus Single-Injection Peripheral Nerve Blocks: A Prospective Cohort Study Comparing Procedural Time and Estimated Personnel Cost

Background and Objectives: Continuous peripheral nerve blocks (CPNB) provide many additional benefits compared to single-injection peripheral nerve blocks (SPNB). However, the time and costs associated with CPNB provision have not been previously considered. The objective of this study was to compare the time required and estimated personnel costs associated with CPNB and SPNB. Methods: This IRB-exempt observational study involved provision of preoperative regional anesthesia procedures in a “block room” model by a dedicated team during routine clinical care. The primary outcome, the time to perform ultrasound-guided popliteal-sciatic blocks, was recorded prospectively. This time measurement was broken down into individual tasks: time to place monitors, prepare the equipment, scan and identify the target, perform the block, and clean up post-procedure. For peripheral nerve block catheters, time to insert, locate, and secure the catheter was also recorded. Cost estimates for physician time were determined using published national mean hourly wages. Results: Time measurements were recorded for 24 nerve block procedures (12 CPNB and 12 SPNB). The median (IQR; range) total time (seconds) taken to perform blocks was 1132 (1083-1290; 1060-1623) for CPNB versus 505 (409-589; 368-635) for SPNB (Table 1; p&lt;0.001). The median (IQR) cost attributed to physician time during block performance was $35.20 ($33.66-$40.11) and $15.69 ($12.73-$18.32) for CPNB and SPNB, respectively. Conclusion: CPNB requires approximately 10 more minutes per procedure to perform when compared to SPNB. This additional time should be considered along with potential patient benefits and available resources when developing a regional anesthesia and acute pain medicine service.

Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care.

Why the Perioperative Surgical Home Makes Sense for Veterans Affairs Health Care.

The training and careers of regional anesthesiology and acute pain medicine fellows, 2013.

Fellowships in regional anesthesiology and acute pain medicine (RAAPM) have grown exponentially during the past decade, both in terms of total programs and fellows trained. This survey-based study reports fellowship graduates' assessment of the strengths and weaknesses of their training and how the fellowship has affected their careers. Graduates of North American RAAPM fellowships were asked to participate in a 16-question survey designed to describe their training and subsequent career. Academic anesthesiology department chairs were simultaneously surveyed to determine how the RAAPM components of their residency training programs are staffed and organized. Graduate and department chair response rates were 59% and 44%, respectively. During the past decade, significant improvements have occurred in peripheral nerve block, perineural catheter, and acute pain medicine training. Many fellowship graduates note less robust educational experiences in research and the nontechnical aspects of the subspecialty. The results of this study should prove useful to fellowship directors as they refine the educational offerings of their programs.

Guidelines for fellowship training in regional anesthesiology and acute pain medicine: third edition, 2014.

Directors for Regional Anesthesiology and Acute Pain Medicine fellowships develop and maintain guidelines for fellowship training in the subspecialty. The first edition of the guidelines was published in 2005 with a revision published in 2010. This set of guidelines updates the 2010 revision. The guidelines address 3 major topics: organization and resources, the educational program, and the evaluation process.

Regional Anesthesia and Ischemic Pain: Go with the Flow

The launch of a new section on acute pain in this journal [1], followed by the formation of a new Special Interest Group on this topic by the academy [2], have helped break down compartmental thinking separating acute pain medicine and the management of long-term or recurrent painful conditions. The physiological circumstance of ischemia lies at the crossroads between acute and chronic pain, offering an opportunity for mutually beneficial crosstalk between those who primarily focus upon acute vs chronic pain. Ischemia can befall any organ to produce deleterious, disastrous, or even fatal consequences. Cardiac ischemia responds to thoracic epidural analgesia, which has been applied perioperatively during cardiac surgery as well as chronically in the treatment of outpatients with angina [3]. Chronic symptomatic ischemia of the spine and lumbar nerve roots, i.e., neurogenic claudication of the lower extremities as seen in spinal stenosis, is less responsive to epidural analgesia. Since the invention of this technique by Bier in 1908, deliberate tourniquet ischemia of an extremity has been combined with instillation of local anesthetic …

Acute Pain Medicine: Show Me the Data

This month in Pain Medicine researchers Duncan et al. ⇓ present their review of the emerging practice of acute pain medicine within the United Kingdom (UK) health system. The timeliness of this manuscript and topic is particularly poignant with the recent American Academy of Pain Medicine announcement of the creation of an Acute Pain Medicine Special Interest Group (http://www.painmed.org/acute/) and publication of the Group's mission statement in this journal ⇓. From a historic perspective perhaps it is understandable that both health systems would be exploring in greater detail the emerging pain medicine sub-specialty field of acute pain medicine. After all, the United States (US) and UK have been staunch allies during all of the major 20th century conflicts and that relationship has continued during the most recent conflicts. War, while representing the human species at its very worst, is a catalyst for medical change and innovation. In fact, the first US military acute pain service to serve wounded in the Afghanistan War was accomplished within a UK lead combat support hospital ⇓. I believe the collective experience both countries have gained in the past decade dealing with war casualties has highlighted the importance of …

Bridging the gap between acute perioperative pain and chronic pain medicine

Bridging the gap between acute perioperative pain and chronic pain medicine

Acute pain medicine in anesthesiology

The American Academy of Pain Medicine and the American Society for Regional Anesthesia have recently focused on the evolving practice of acute pain medicine. There is increasing recognition that the scope and practice of acute pain therapies must extend beyond the subacute pain phase to include pre-pain and pre-intervention risk stratification, resident and fellow education in regional anesthesia and multimodal analgesia, as well as a deeper understanding of the pathophysiologic mechanisms that are integral to the variability observed among individual responses to nociception. Acute pain medicine is also being established as a vital component of successful systems-level acute pain management programs, inpatient cost containment, and patient satisfaction scores. In this review, we discuss the evolution and practice of acute pain medicine and we aim to facilitate further discussion on the evolution and advancement of this field as a subspecialty of anesthesiology.

The Acute Pain Medicine Special Interest Group (APMSIG): Table 1

The Perioperative and Acute Pain section of Pain Medicine , with Andre Boezaart, MD, PhD, and I serving as co-editors, was launched with an editorial in September 2009 ⇓. The section grew from discussions we were both having with Rollin “Mac” Gallagher, Editor-in Chief of Pain Medicine , concerning the continuum of personal experience that is pain medicine. We recognized, like many of our colleagues, that the experience and pathophysiology of acute pain was an area of pain medicine worthy of study and focused patient therapy. The experience of acute pain is vital for our survival, yet its persistence or “chronification” can lead to the devastating illness of chronic pain. In my own career, I have witnessed too many soldiers, whose traumatic wounds have healed and shattered bones mended, who continue to struggle with pain on a daily basis. I know from 12 years of working with the combat wounded in the acute pain medicine (APM) setting that the rehabilitation of the wounded, both mentally and physically, cannot begin until the pain is managed. It has been from this experience that the study and practice of APM has developed into the defining passion and interest of my career as a physician. When I first deployed to Iraq in 2003, I was an anesthesiologist with highly developed skills in regional anesthesia. I have since evolved, spurred forward by the catalyst for medical change that is war, into an APM physician. I am not the first anesthesiologist to make this change to APM, and I …

Interview: 21st Century Battlefield Pain Management

Colonel Chester 'Trip' Buckenmaier 3rd, MD, speaks to Dominic Chamberlain, Assistant Commissioning Editor: Colonel Buckenmaier is the current Director of the Defense and Veterans Center for Integrative Pain Management (MD, USA) and Fellowship Director of the Acute Pain Medicine and Regional Anesthesia program at Walter Reed National Military Medical Center in Washington DC (USA). He is an Associate Professor in Anesthesiology at the Uniformed Services University of the Health Sciences in Bethesda (MD, USA), and a Diplomat with the American Board of Anesthesiology. He attended Catawba College (NC, USA), on a Reserve Officers' Training Corps (ROTC) scholarship, graduating with a degree in Biology and Chemistry in 1986. He then attended East Carolina University in Greenville (NC, USA), receiving a Master in Science in Biology in 1988. In 1992, he graduated from the Uniformed Services University of the Health Sciences, completing his Anesthesia Residency at Walter Reed. In addition, he completed a 1-year Fellowship in Regional Anesthesia at Duke University (NC, USA) in 2002, resulting in the creation of the only Acute Pain Medicine Fellowship in the US military at Walter Reed (Washington, DC, USA). In September 2003, he deployed with the 21st Combat Support Hospital to Balad (Iraq), and demonstrated that the use of advanced regional anesthesia can be accomplished in a forward deployed environment. He performed the first successful continuous peripheral nerve block for pain management in a combat support hospital. In April 2009, he deployed to Camp Bastion (Afghanistan) with the British military and ran the first acute pain service in a theater of war. The Defense and Veterans Center for Integrative Pain Medicine (DVCIPM) is dedicated to improving pain management throughout the continuum of care for service personnel and their families.

Journal Watch: Our Expert Highlights the Most Important Research Articles Across the Spectrum of Topics Relevant to the Field of Pain Management

Pain ManagementVol. 3, No. 3 News & ViewsFree AccessJournal Watch: Our expert highlights the most important research articles across the spectrum of topics relevant to the field of pain managementJohn D LoeserJohn D LoeserUniversity of Washington, WA, USASearch for more papers by this authorPublished Online:30 Apr 2013https://doi.org/10.2217/pmt.13.19AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail This is a superb treatise on the history, growth and development of acute pain medicine (APM). It lays out the reasons for such a service, and indeed, a potential specialty. Clearly a subdivision of anesthesiology, the movement to articulate APM as a specialty helps to clarify the differences between the management of acute and chronic pain, and the type of training and experience that each area requires. The authors have thoroughly described the role that APM can play in modern healthcare and have provided an example of what every hospital should aspire to for patient safety and comfort. The authors discuss the education and training of acute pain physicians and the support personnel that are required to run an effective service. The use of protocols to determine patient management is emphasized. A brief section on cost–effectiveness lays out the issues for APM. In the oncoming era of the Accountable Care Organization in the USA, justifying the costs of one’s service is critical. I believe that the authors have staked out a valid claim for the development of a new subspecialty of anesthesiology while making it quite clear that chronic pain management belongs in a different medical domain, even though they do not really address the issues for chronic pain at all.The authors set out to determine if anxiety and social stressors predicted 12-month outcomes in a multidisciplinary primary care intervention. They also looked at whether early changes (within the first 3 months) predicted 12-month outcomes. The 250 subjects for this study were musculoskeletal pain patients involved in a randomized clinical trial of a combined medication and behavioral intervention versus care as normal. A prior study had demonstrated that patients randomized to the intervention arm manifested moderate relief of pain and significantly decreased depression. This study looked for predictive variables at baseline. Anxiety was assessed using the Generalized Anxiety Disorder-7 scale, social stress was measured with Patient Health Questionnaire-9. The Symptom Checklist-20 and Brief Pain Inventory were used to assess depression and pain levels. Anxiety severity at baseline, as well as early improvement in anxiety, were independent predictors of both depression and pain severity at 12 months. Social stressors at baseline or their reduction by 3 months did not predict depression or pain severity at 12 months. This study emphasizes the importance of addressing comorbid anxiety in the successful treatment of chronic pain patients. There is always more than occult pathology that the pain physician must address.This rodent study addresses a proposed mechanism for allodynia and comes to the fascinating conclusion that Na+–K+–Cl- cotransporter 1 (NKCC1) plays an important role in the genesis of this sensory abnormality. It is well known that stimulation of peripheral nociceptors leads to increased c-Fos labeling in spinal cord regions that are involved in nociceptive information processing. By contrast, light stimulation of abdominal skin does not result in c-Fos labeling or pain behavior. However, if the mouse is given intracolonic capsaicin, lightly stroking the abdominal skin leads to pain behavior and increased c-Fos labeling in the spinal cord nociceptive regions. Previous work by these authors has shown that the afferent activity in low-threshold sensory fibers activates nociceptive sensory fibers via NKCC1 enhanced primary afferent depolarization. In this study, the NKCC1 blocking agent bumetanide was administered intrathecally and markedly reduced both the allodynia and the c-Fos expression after intracolonic capsaicin. It has been suggested that NKCC1 is the principal determinant of intracellular chloride in dorsal root ganglion neurons, and upregulation of this agent could result in exaggerated primary afferent depolarization sufficient to produce depolarization of nociceptor terminals – that is, presynaptic inhibition becomes presynaptic excitation. The search for mechanisms of chronic pain states is illuminated by this study.Financial & competing interests disclosureThe author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.FiguresReferencesRelatedDetails Vol. 3, No. 3 Follow us on social media for the latest updates Metrics Downloaded 245 times History Published online 30 April 2013 Published in print May 2013 Information© Future Medicine LtdPDF download

The Insiders' Experiences with Continuous Transversus Abdominis Plane Blocks for Analgesia After Cesarean Delivery

Transversus abdominis plane blocks have been recently utilized for analgesia after cesarean delivery. However, little data concerning continuous transversus abdominis plane blocks has been reported in the existing literature. Available studies mainly examine the efficacy of single-injection blocks, and only one small case series has been published regarding continuous blocks for analgesia after cesarean delivery. First-hand experiences and observations of three acute pain medicine specialists who received a continuous transversus abdominis plane block for analgesia after cesarean delivery are presented. Three physicians specialized in acute and perioperative pain medicine personally underwent continuous transversus abdominis plane block placements for analgesia after cesarean delivery via a disposable infusion pump at the same teaching hospital. In a very motivated, well-supported, and informed patient after uncomplicated cesarean delivery, the use of continuous transversus abdominis plane blocks for analgesia offers the significant advantages of early functional recovery and excellent prolonged analgesia. The patients experienced postoperative continuous transversus abdominis plane blocks that seem to be of value in limiting opiate use and improving analgesia with daily activities in the acute postoperative phase after cesarean delivery.

The evolution and practice of acute pain medicine.

In recent years, the field of acute pain medicine (APM) has witnessed a surge in its development, and pain has begun to be recognized not merely as a symptom, but as an actual disease process. This development warrants increased education of residents both in the performance of regional anesthesia as well as in the disease course of acute pain and the biopsychosocial mechanisms that define interindividual variability. We reviewed the organization and function of the modern APM program. Following a discussion of the nomenclature of acute pain-related practices, we discuss the historical evolution and modern role of APM teams, including the use of traditional, as well as complementary and alternative, therapies for treating acute pain. Staffing and equipment requirements are also evaluated, in addition to the training requirements for achieving expertise in APM. Lastly, we briefly explore future considerations related to the essential role and development of APM. The scope and practice of APM must be expanded to include pre-pain/pre-intervention risk stratification and extended through the phase of subacute pain.