Adjuvant Analgesics Research Articles

Redefining the Role of Analgesic Adjuvants in Pain Management: A Narrative Review

Conventional analgesics have traditionally been the mainstay of pain management, but unsatisfactory pain relief and troubling side effects have led to continuing search for more efficacious and safer remedies. Adjuvant analgesics are drugs with beneficial analgesic effects despite not having been developed as analgesics. Adjuvants facilitate better pain control with a reduction in analgesic consumption, as well as the concomitant side effects. The opioid epidemic, deaths from opioid overdose, and several other complications of opioid-based analgesia have led to increasing interrogation of its use in both acute and chronic pain settings. The current trends in surgical practice, especially ambulatory surgery and enhanced recovery after surgery/fast-track care pathways have profoundly impacted the choices for acute pain management, with an increasing role for adjuvants. Medicinal cannabis and other adjuvants have also become increasingly popular for the management of intractable chronic pain and neuropathic pain owing to the inadequacy of conventional analgesics in these pain states. As clinical and research interest in patient safety and patient satisfaction evolve further development of adjuvant analgesics will be expected to fill the existing gaps in pain management. This review aims to examine the expanding role of analgesic adjuvants in the management of acute and chronic pains, and in the prevention of the transition to chronic pain. In doing so, we conducted an online search primarily on the PUBMED database using the term “analgesic adjuvant” for human studies published in peer-reviewed journals from 2000 to 2022.

Comparison of dexmedetomidine and ketamine in adjuvant with morphine for postoperative pain management following lumbar fusion surgery

BackgroundPostoperative pain leads to increased opioid consumption and associated adverse effects. Adjuvant analgesia can improve pain management and reduce opioid consumption. This study aimed to compare the analgesic effects of adjuvants of dexmedetomidine and ketamine with morphine in patients with lumbar fusion. Patients and methodsIn this double-blind randomized clinical trial, patients undergoing elective lumbar fusion surgery were included. These patients were randomly divided into three groups. Group D received 50 μg dexmedetomidine and 20 mg of intravenous morphine, group K received 50 mg of ketamine and 20 mg of intravenous morphine, and control group C received 20 mg of intravenous morphine with normal saline (100 cc) in the form of PCA (patient-controlled analgesia) pump. The severity of pain after surgery was assessed using a visual analog scale (VAS) 2, 6, and 24 postoperative hours. Nausea and vomiting after the surgery, the amount of drug consumption from the PCA pump, and the duration of hospital stay were also evaluated. ResultsOf 196 patients included in the study, 69.4 % were males and 30.6 % were females. At 2,6 and 24 postoperative hours, the pain was significantly less in group D, compared to groups K and C, p < 0.05. However, in all three groups, pain was significantly reduced at all time intervals, p < 0.05. Group C had significantly the greatest incidence of postoperative nausea and vomiting, ileus, and prolonged hospitalization, p < 0.05. ConclusionsThe results of this study showed that postoperative pain management with the adjuvant of dexmedetomidine and morphine is most effective in terms of pain, adverse effects, hospitalization, and patient satisfaction. It is also superior to ketamine and morphine adjuvant and morphine alone, respectively.

Analgesic Profile in Intensive Observation Room (Ruang Observasi Intensif/ ROI) Dr. Soetomo General Hospital Surabaya

Introduction: Pain is a condition that the majority of critical care patients will possibly suffer at some point during their stay in the intensive care unti (ICU). In both medical and surgical ICU patients, the incidence of considerable pain is still 50% or greater. Analgesic administration is considered one of the most effective pain managements. While useful, it can cause detrimental effects if not used according to its indications and regulations.Objective: To obtain the analgesic profile used in intensive observation room (ruang observasi intensif/ROI) Dr. Soetomo General Hospital Surabaya.Methods: This study is a retrospective descriptive study with 537 medical records met the inclusion criteria.Result: The most frequent analgesic used is metamizole (44.41%) and paracetamol (16.08%) while ketamine was used the least (0.24%). Most commonly used analgesic adjuvants is phenytoin (6.12%). The amount of single drug administration (52.70%) is more frequent than multimodal analgesic (47.30%). Metamizole with paracetamol is the most popular analgesic combination (20.74%), followed by metamizole with tramadol (14.17%), and metamizole with fentanyl (12.99%). The most common procedures recorded are obstetrics and gynaecological (29.98%), cranial and general surgery with the same result (21.42%), and orthopaedic (12.29%). 205 samples with Wong-Baker FACES Pain Ratings Scales stated that there is an increase in patients who do not experience pain after administration of analgesics (N=25 to N=132), patients that underwent mild pain decreased (N=134 to N=65), and patients with moderate and severe pain also decreased (N=43 to N=8 and N=3 to N=0 respectively).Conclusion: Non-opioid analgesic dominates the analgesic profile in ROI Dr. Soetomo General Hospital Surabaya compared to opioids that generally used the most worldwide. Giving analgesics to patients has been proven successful in reducing the pain degree.

MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse events

Approximately 18% of patients with cancer use cannabis at one time as palliation or treatment for their cancer. We performed a systematic review of randomized cannabis cancer trials to establish a guideline for its use in pain and to summarize the risk of harm and adverse events when used for any indication in cancer patients. A systematic review of randomized trials with or without meta-analysis was carried out from MEDLINE, CCTR, Embase, and PsychINFO. The search involved randomized trials of cannabis in cancer patients. The search ended on November 12, 2021. The Jadad grading system was used for grading quality. Inclusion criteria for articles were randomized trials or systematic reviews of randomized trials of cannabinoids versus either placebo or active comparator explicitly in adult patients with cancer. Thirty-four systematic reviews and randomized trials met the eligibility criteria for cancer pain. Seven were randomized trials involving patients with cancer pain. Two trials had positive primary endpoints, which could not be reproduced in similarly designed trials. High-quality systematic reviews with meta-analyses found little evidence that cannabinoids are an effective adjuvant or analgesic to cancer pain. Seven systematic reviews and randomized trials related to harms and adverse events were included. There was inconsistent evidence about the types and levels of harm patients may experience when using cannabinoids. The MASCC panel recommends against the use of cannabinoids as an adjuvant analgesic for cancer pain and suggests that the potential risk of harm and adverse events be carefully considered for all cancer patients, particularly with treatment with a checkpoint inhibitor.

Pain: a neglected symptom in hemophilia.

Repetitive bleeding attacks may cause joint pain and arthropathy in patients with hemophilia (PWH). Despite being a common symptom, pain is not a well-studied topic in this disease. The aim of this cross-sectional, observational study was to assess the frequency and intensity of pain and analyze the success rates ofpain treatment methods. Adult hemophilia patients were included in the study. The Multidimensional Hemophilia Pain Questionnaire (MHPQ) was used to assess pain. In addition to the MHPQ, demographic data were collected. Fifty adult hemophilia patients were included in the study. Thirty-one (62%) of the patients reported pain due to hemophilia in the last year. Twenty-six of them (81.2%) reported pain during bleeding attacks. The most successful pain coping strategy was clotting factor replacement. None of the participants used opioids or adjuvant analgesics. None of them used a physical therapy modality or interventional pain therapy method. While 67.6% of the patients were very dissatisfied or dissatisfied with their global pain treatment, only 16.1% of the patients were satisfied or very satisfied. Patients with higher pain during bleeding episodes were more likely to continue their prophylaxis. There was no significant difference between plasma-derived or recombinant-derived factor prophylaxis in terms of pain complaints. Pain is a frequent and important symptom of hemophilia, but most of the patients are not treated sufficiently. A multidisciplinary approach is needed to improve the life quality of the patients. In addition to successful bleeding prophylaxis, administration of a proper and adequate analgesic regimen and combined physical therapy modalities may decrease pain intensity and prevent the development of arthropathy.

The heptapeptide somatostatin analogue TT-232 exerts analgesic and anti-inflammatory actions via SST4 receptor activation: In silico, in vitro and in vivo evidence in mice

Since the conventional and adjuvant analgesics have limited effectiveness frequently accompanied by serious side effects, development of novel, potent pain killers for chronic neuropathic and inflammatory pain conditions is a big challenge. Somatostatin (SS) regulates endocrine, vascular, immune and neuronal functions, cell proliferation through 5 Gi protein-coupled receptors (SST1-SST5). SS released from the capsaicin-sensitive peptidergic sensory nerves mediates anti-inflammatory and antinociceptive effects without endocrine actions via SST4. The therapeutic use of the native SS is limited by its diverse biological actions and short plasma elimination half-life. Therefore, SST4 selective SS analogues could be promising analgesic and anti-inflammatory drug candidates with new mode of action. TT-232 is a cyclic heptapeptide showing great affinity to SST4 and SST1. Here, we report the in silico SST4 receptor binding mechanism, in vitro binding (competition assay) and cAMP- decreasing effect of TT-232 in SST4-expressing CHO cells, as well as its analgesic and anti-inflammatory actions in chronic neuropathic pain and arthritis models using wildtype and SST4-deficient mice. TT-232 binds to SST4 with similar interaction energy (-11.03 kcal/mol) to the superagonist J-2156, displaces somatostatin from SST4 binding (10 nM to 30 µM) and inhibits forskolin-stimulated cAMP accumulation (EC50: 371.6 ± 58.03 nmol; Emax: 78.63 ± 2.636 %). Its i.p. injection (100, 200 µg/kg) results in significant, 35.7 % and 50.4 %, analgesic effects upon single administration in chronic neuropathic pain and repeated injection in arthritis models in wildtype, but not in SST4-deficient mice. These results provide evidence that the analgesic effect of TT-232 is mediated by SST4 activation, which might open novel drug developmental potentials.Chemical compoundsChemical compounds studied in this article TT-232 (PubChem CID: 74053735).

Painful diabetic polyneuropathy: modern approaches to diagnosis and treatment

Diabetes mellitus is one of the most common chronic diseases, the incidence of which is steadily increasing. Approximately 1 in 11 adults in the world today has diabetes. Diabetic polyneuropathy is a common complication of diabetes mellitus and leads to a decrease in the quality and life expectancy of patients, increases the risk of disability. The pain form of diabetic polyneuropathy has a particularly negative effect on the quality of life. It includes both acute (Ellenberg’s neuropathy and acute insulin-induced neuropathy) and chronic forms. The article discusses modern ideas about the pathogenesis of pain diabetic polyneuropathy, as well as risk factors, clinical symptoms and diagnostic methods (electroneuromyography, quantitative sensory testing, sudomotor function, skin biopsy, confocal biopsy of the cornea) of the disease. In most patients, the pain form of diabetic polyneuropathy is accompanied by autonomic disorders. Treatment of painful diabetic polyneuropathy is a difficult task, including the correction of risk factors (glycemia level, patient lifestyle), as well as pathogenetic and symptomatic therapy. As symptomatic therapy, adjuvant analgesics are used, namely drugs from the group of anticonvulsants (gabapentin, pregabalin) and antidepressants (duloxetine). The use of alpha-lipoic acid is the basis of pathogenetic therapy. As a universal antioxidant, alpha-lipoic acid is an absolutely safe drug with a proven effect in the treatment of painful diabetic polyneuropathy and can be recommended for use in clinical practice.

Two Dosages of Dexamethasone (2 mg and 4 mg) as Analgesic Adjuvant to Levobupivacaine in Ultrasound-guided Brachial Plexus Block in Upper Limb SurgeryA Randomised Clinical Trial

Introduction: Perineural dexamethasone gives promising results in prolonging duration of analgesia in brachial plexus block. Doses between 1 to 10 mg have been used but the optimum dose is not yet settled. Aim: To compare the analgesic efficacy of two low doses of dexamethasone in Ultrasonography (USG)-guided brachial plexus block for planned upper limb surgery. Materials and Methods: A double-blind randomised clinical trial was conducted with 126 adult patients of either sex, randomised in equal numbers to 2 mg and 4 mg dexamethasone groups, the steroid being administered in conjunction with 0.5% levobupivacaine. Time to onset of sensory and motor blocks, duration of analgesia, duration of motor block, total consumption of analgesics in the first 24 hours postoperative period, haemodynamic parameters and features of neurotoxicity were compared. Tramadol 50mg intravenous was permitted as rescue analgesic. Results: No significant differences in onset of sensory and motor blocks were encountered. Duration of sensory block with 4 mg {median (Interquartile range); 1080 (900-1140) min} clearly exceeded that with 2 mg {840 (720-960) min} (p-value&lt;0.001) dexamethasone. Duration of motor block was also greater with 4 mg dexamethasone {1080 (1020-1170) versus 870 (810-990)min} (p-value&lt;0.001). Total analgesic consumption in first 24 hours was 225 (175-250) mg versus 100 (75-200) mg in 2 mg and 4 mg groups respectively (p-value&lt;0.001). No features of neurotoxicity were encountered in either group. Conclusion: Perineural dexamethasone 4 mg gives better results as analgesic adjuvant to bupivacaine compared to 2mg in brachial plexus block for upper limb surgery without increasing adverse effects.

Inhibitory Actions of Clinical Analgesics, Analgesic Adjuvants, and Plant-Derived Analgesics on Nerve Action Potential Conduction

The action potential (AP) conduction in nerve fibers plays a crucial role in transmitting nociceptive information from the periphery to the cerebral cortex. Nerve AP conduction inhibition possibly results in analgesia. It is well-known that many analgesics suppress nerve AP conduction and voltage-dependent sodium and potassium channels that are involved in producing APs. The compound action potential (CAP) recorded from a bundle of nerve fibers is a guide for knowing if analgesics affect nerve AP conduction. This entry mentions the inhibitory effects of clinically used analgesics, analgesic adjuvants, and plant-derived analgesics on fast-conducting CAPs and voltage-dependent sodium and potassium channels. The efficacies of their effects were compared among the compounds, and it was revealed that some of the compounds have similar efficacies in suppressing CAPs. It is suggested that analgesics-induced nerve AP conduction inhibition may contribute to at least a part of their analgesic effects.

ANESTHESIA OR SEDATION OF NEWBORNS IN INTENSIVE CARE: HOW TO DETERMINE THE OPTIMAL WAY?

During their stay in the intensive care unit, newborns are subjected to an enormous number of painful procedures and operations. Poorly treated pain during the newborn period can lead to negative remote effects such as cognitive dysfunction, the formation of chronic pain. Therefore, every day reanimatologists accept the challenge to evaluate the pain adequately and to choose right analgesia tactics. The literature review represents the analysis of 87 literary sources over the past 10 years. This article covers the results of multicenter studies and clinical recommendations. It has been determined that optimal treatment of pain and anxiety in newborns requires a multimodal approach, always including non-medication strategies and directed primarily to analgesia. Placing on the chest and breastfeeding, sucking reflex, «skin to skin» contact, «kangaroo» care, swaddling – all these aspects of childcare are effective to reduce physiological and behavioural response to pain in invasive procedures, and also have sedative effect. Every manipulation requires a mandatory analgesic. The choice of the method of anesthesia depends on the invasiveness of the procedure, gestational age and the severity of the condition of the child. It is advisable to combine various non-medication analgesic methods for mild pain, to add medication methods for moderate and severe pain to achieve better therapeutic effect. Neonates who are on prolonged ventilation cannot avoid sedation. However, sedation can be achieved by a combination of non-medication methods and sedatives. In order to prevent tachyphylaxis, analgesics should be rotated, and combinations of opiates with non-narcotic analgesics and adjuvant analgesics should be used. The multimodal approach to pain treatment has the benefits of reducing the dosage of any single drug and mitigating the overall risk of side effects. Acetaminophen, fentanyl or morphine in combination with midazolam are the safest medicines for use in newborns, despite the side effects.

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study

BackgroundCirculatory and respiratory depression are common problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or colonoscopy. However, it is still unknown the median effective dose (ED50) of propofol when combined with lidocaine intravenously. This study aimed to compare the ED50 of propofol with or without intravenous lidocaine for inserting gastrointestinal endoscope successfully.MethodsFifty nine patients undergoing gastroscopy or gastrointestinal (GI) endoscopy were randomly divided into control group (Group C, normal saline + propofol) or lidocaine group (Group L, lidocaine + propofol). Patients were initially injected a bolus of 1.5 mg/kg lidocaine in Group L, whereas equivalent volume of 0.9% saline in Group C. Anaesthesia was then induced with a single bolus of propofol in all subjects. The induction dose of propofol was determined by the modified Dixon’s up-and-down method, and the initial dose was 1.5 mg/kg in both groups. The primary outcome was the ED50 of propofol induction dose with or without intravenous lidocaine. The secondary outcomes were the induction time, the first propofol bolus time (FPBT: from MOAA/S score ≤ 1 to first rescue bolus propofol), and adverse events (AEs: hypoxemia, bradycardia, hypotension, and body movements).ResultsTotally, 59 patients were enrolled and completed this study. The ED50 of propofol combined with lidocaine was 1.68 ± 0.11 mg/kg, significantly reduced compared with the normal saline group, 1.88 ± 0.13 mg/kg (P = 0.002). There was no statistical difference in induction time (P = 0.115) and the FPBT (P = 0.655) between the two groups. There was no significantly difference about the AEs between the two groups.ConclusionThe ED50 of propofol combined with intravenous lidocaine for successful endoscope insertion in adult patients, was 1.68 ± 0.11 mg/kg significantly reduced compared with the control group.Trial registrationChinese Clinical Trial Registry, No: ChiCTR2200059450. Registered on 29 April 2022. Prospective registration. http://www.chictr.org.cn.

The therapeutic potential of ultra-short-acting β-receptor antagonists in perioperative analgesic: Evidence from preclinical and clinical studies.

Perioperative multimodal analgesia can reduce the side effects of a high concentration of opioids, improving the comfort of the patient. However, insufficient analgesia of this model has prompted researchers to explore new adjuvant analgesics. Recently, an increasing number of studies have found a low-grade analgesic effect in the clinical application of ultra-short-acting β-adrenergic receptor antagonists, which are conventionally used as pharmacologic agents in the cardiovascular system. The mechanism by which ultra-short-acting β-antagonists exert antinociceptive effects has not been clarified yet. In this review, we intend to address its potential reasons from the side of neurotransmitters, inflammatory cytokines, and signaling pathways, providing theoretical proof for the application of β-adrenergic receptor antagonists in analgesia.

Postoperative Pain in Outpatient Orthopedic Foot and Ankle Trauma Surgery Patients

Category: Trauma Introduction/Purpose: Opioid pain medications are frequently prescribed after orthopedic surgery as effective tools for pain relief, but with adverse consequences such as addiction and overdose. Postoperative pain control can vary depending on patient opioid prescription history and pain expectations. There are limited studies regarding pain and anxiety levels following orthopedic foot and ankle trauma surgery, with a lack of formal guidelines in prescribing opioid medications to this patient population. The overall purpose of this study was to gain an understanding of postoperative pain and anxiety in patients undergoing outpatient foot and ankle trauma surgery. This study additionally sought to identify any risk factors that may predispose a patient to increased postoperative pain and anxiety, resulting in a potentially increased pain medication requirement. Methods: A subanalysis of 50 patients from a prospective, observational study was performed, examining adult patients undergoing outpatient foot and ankle trauma surgery performed by trauma fellowship-trained senior investigators. Patients were enrolled and given pertinent reference materials including access to an automated texting survey platform to collect data regarding their postoperative pain, anxiety, and opioid medication use. Patients were stratified by procedure type (irrigation &amp; debridement/hardware removal, foot/syndesmosis ORIF, ankle ORIF, pilon ORIF) and by receiving perioperative regional anesthetic block versus local anesthetic. Pain and anxiety were measured with the Numeric Rating Scale for Pain (scale of 1-10) and the Visual Facial Anxiety Scale (scale of 1-5), respectively. The primary outcome measured was the number of days on average for a patient to discontinue opioid medication. Secondary endpoints consisted of pain level &lt; 4, anxiety level &lt; 2, patient-specific and surgery-related factors that may affect these variables. Results: Postoperatively, it took an average of 9.6 days until opioids were discontinued, 8.2 days for pain to subside below 4, and 6.6 days until anxiety reduced under 2. Foot/syndesmosis ORIF and older age were associated with prolonged pain medication use (p&lt;0.05). Drug use and older age limited the chance of obtaining a pain score under 4 (p&lt;0.05). Psychiatric history and older age decreased the odds of obtaining an anxiety score under 2 (p&lt;0.05). White race improved the chance of obtaining an anxiety score under 2 and tapering off pain medications (p&lt;0.05). When stratified by procedure type or analgesic adjuvants (regional block vs local), there were no significant differences in pain and anxiety scores. Conclusion: Our study shows that regardless of procedure type or analgesic adjuvant used, it takes approximately eight days for postoperative pain levels to decrease to 4 out of 10 and six days for anxiety levels to decrease to 2 out of 5, with patients requiring opioid pain medications for an average of 10 days. Risk factors such as older age, prior drug use, and psychiatric history increased postoperative pain, anxiety, and use of opioid pain medications. This data may be utilized by orthopedic surgeons in providing safe, effective, and evidence-based pain management prescribing practices in anticipating postoperative pain and anxiety.

Analgesic adjuvants for brachial plexus block - A narrative review

Ultrasound guided brachial plexus block is gaining importance as it provides excellent surgical anaesthesia, nonsurgical analgesia, immobilisation of limb and reduces general anaesthesia related side effects. The technique also has the advantage of visualisation of needle towards the nerve of interest and deposition of drug with immediate anaesthesia and patient satisfaction thereby decreasing the chances of vascular injury. Local anaesthetics when given in large doses can cause systemic toxicity whereas when given as single shot or in smaller dose fail to either produce desired effect or duration of action exposing the patient to the pain of surgical trauma. To overcome this, various class of drugs have been used as adjuvants to local anaesthetics and their efficacy are studied through the quality of block produced, known as analgesic adjuvants. In this review, we aim to discuss a few studies regarding the use of various adjuvants for brachial plexus block and provide current evidence for use and also summarizes the best strategies for optimizing pain control and reducing adverse effects after surgery under brachial plexus block.

Effects of intravenous lidocaine on hypoxemia induced by propofol-based sedation for gastrointestinal endoscopy procedures: study protocol for a prospective, randomized, controlled trial

BackgroundOxygen-desaturation episodes, blood pressure drops, and involuntary body movement are common problems that occur in propofol-based sedation in the procedure of painless gastrointestinal (GI) endoscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during ERCP or colonoscopy. However, it is still unknown how lidocaine affects the incidence of oxygen-desaturation episodes and cardiovascular events, and involuntary movement during painless GI endoscopy. Therefore, we aimed to assess the effectiveness and safety of intravenous lidocaine in propofol-based sedation for GI endoscopy.MethodsWe will conduct a single-center, prospective, randomized, double-blind, saline-controlled trial. A total number of 300 patients undergoing painless GI procedures will be enrolled and randomly divided into the lidocaine group (Group L) and the control group (Group C). After midazolam and sufentanil intravenous injection, a bolus of 1.5 mg/kg lidocaine was immediately injected and followed by a continuous infusion of 4 mg/kg/h in the lidocaine group, whereas the same volumes of saline solution in the control group. Then, propofol was titrated to produce unconsciousness during the procedure. The primary outcome will be the incidence of oxygen-desaturation episodes. Secondary outcomes will be the incidence of involuntary body movement, discomfort symptoms, propofol consumption, endoscopist, and patient satisfaction.DiscussionPropofol-based deep sedation without intubation is widely used in painless GI endoscopy. However, adverse events such as hypoxemia often occur clinically. We expect to assess the effect of lidocaine on reducing the incidence of oxygen-desaturation episodes, cardiovascular events, and involuntary body movement. We believe that the results of this trial will provide an effective and safe method for painless GI endoscopy.Trial registrationChinese Clinical Trial Registry ChiCTR2100053818. Registered on 30 November 2021.

Prevalence of Delirium in Advance Cancer Patients Admitted in Hospice Centre and Outcome after Palliative Intervention.

The assessment of prevalence of delirium in advanced cancer patients admitted in hospice centre and outcome after palliative intervention. The possible related risk factors for development of delirium. This was prospective analytic study done at hospice centre attached with tertiary cancer hospital in Ahmedabad during August 2019 - July 2021. This study was approved by the Institutional Review Committee. We selected patients according to following inclusion criteria (all patient admitted to hospice centre above 18 years, with advance cancer disease and on best supportive care) and exclusion criteria (Lack of informed consent, Inability to participate in study due to mentally retard or coma). The following information were collected: age, gender, address, type of cancer, comorbidities, history of substance abuse, history of (h/o) palliative chemotherapy or radiotherapy within last 3month, general condition, ESAS (Edmonton symptom assessment scale), ECOG (Eastern cooperative oncology group), PaP score (palliative prognostic score), medication including opioids, NSAIDs (Non-steroidal anti-inflammatory drugs), steroids, antibiotic, adjuvant analgesic, PPI (Proton pump inhibitor), anti-emetic etc. Delirium diagnosis was based on diagnostic criterion of DSM-IV text revised and MDAS. In our study we found prevalence of delirium was 31.29% in advanced cancer patients admitted to hospice centre. We found most common type of delirium is hypoactive (34.7%) and mixed subtype (34.7%) followed by hyperactive (30.4%) delirium. Resolution of delirium was higher among hyperactive delirium (78.57%) followed by mixed subtype (50%) and hypoactive (12.5%). Mortality was higher among patient with hypoactive subtype (81.25%) followed by mixed (43.75%) and hyperactive delirium (14.28%). An identification and assessment of delirium is vital for acceptable end of life care within the palliative care in light of the fact that the presence of delirium is related with morbidity, mortality, prolonged ICU hospitalization, expanded time on a ventilator, and by and large more prominent medical services costs. Clinicians should utilize one of a few approved delirium assessment tools to help evaluate and archive cognitive function. Prevention and recognizing the clinical reason for delirium are generally the best method for diminishing the morbidity from delirium. The study results demonstrate that multi component delirium management or projects are generally proficient to lessen the prevalence and negative outcomes of delirium. It was found that palliative care intervention has quite a positive outcome as it not only focus on the mental health of the patients but also of family members who go through the same amount of distress and also help them to communicate properly and manage to settle the mental state and end the life without pain and distress.

Experience in the use of prolonged analgesic peripheral nerve blocks as part of multimodal analgesia regimens in the treatment of patients with gunshot wounds of the limbs

The use of regional analgesic techniques as part of multimodal analgesia regimens provides better control of acute pain. Effective anesthesia is one of the key tasks in the treatment of the wounded at all stages of medical care.&#x0D; Three clinical cases of the use of prolonged regional analgesic blockades as part of a multimodal analgesia regimen in the treatment of patients with gunshot wounds of the extremities are presented. Catheterizations of the perineural space of the peripheral nerves were performed using ultrasound imaging.&#x0D; Clinical case 1 - a patient with a gunshot shrapnel through wound of the left tibia with gunshot comminuted fractures of both bones of the lower third of the left tibia and the upper third of the fibula of the left tibia, was admitted two days after the injury. Performed catheterization of the perineural space of the left sciatic nerve in the popliteal fossa, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. A satisfactory analgesic effect was observed, narcotic analgesics were not prescribed.&#x0D; Clinical case 2 - a patient with a gunshot shrapnel through wound of the left shoulder with a gunshot comminuted fracture of the left humerus in the middle third and with damage to the neurovascular bundle, was admitted more than 6 weeks after the injury. Performed catheterization of the perineural space of the left brachial plexus interscalene access, continuous infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. However, in the absence of complaints of soreness at the fracture sites and postoperative wounds, the patient began to be disturbed by neuropathic pain.Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed. On the second day of observation, dislocation of the catheter was detected.Considering that the patient was more concerned about pain in the distal part of the limb, catheterization of the perineural space of the left brachial plexus was performed by supraclavicular access, and a constant infusion of 0.25 % bupivacaine solution was started at a rate of 5 ml per hour using a perfusor. Satisfactory analgesic effect was observed sporadically, narcotic analgesics were prescribed.&#x0D; Clinical case 3 - a patient with a gunshot shrapnel through wound of the left thigh with a gunshot comminuted fracture of the left femur in the lower third and with damage to the popliteal artery, was admitted three weeks after the injury. Performed paravertebral catheterization of the left lumbar plexus, constant infusion of 0.25 % bupivacaine solution at a rate of 5 ml per hour using a perfusor. In combination with oral analgesic adjuvants (effect on neuropathic pain), a satisfactory analgesic effect was observed without the prescription of narcotic analgesics.After repeated surgical treatment with the installation of the VAC-system on the posterior surface of the thigh, an unsatisfactory effect of non-opiate analgesia was observed, and narcotic analgesics were additionally prescribed.

Meta-analysis on effect of dexamethasone as an analgesic adjuvant to pain treatment after total knee arthroplasty

Background: Pain management after a total-knee arthroplasty (TKA) has become an important issue in the field of medicine. Objective: This study conducted a meta-analysis from randomized controlled trials (RCTs) to assess the efficacy and safety of dexamethasone for pain management after TKA. Methods: PubMed, Medline, Embase, ScienceDirect, and the Cochrane Library were searched up to December 2021 for comparative RCTs involving dexamethasone and placebo for pain control after TKA. Primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes were length of hospital stay, adverse effects, and postoperative complications. We assessed statistical heterogeneity for each RCT with the use of a standard Chi-squared test and the I2 statistic. Results: A total of 5 RCTs were included. The present meta-analysis indicated that there were significant differences between dexamethasone-treated groups and placebo groups regarding postoperative pain scores at 12, 24, and 48hours after TKA. Administering dexamethasone could significantly reduce opioid consumption at 12hours after TKA. However, no significant difference was found in opioid consumption at 24 and 48hours after TKA. There was a decreased risk of adverse effects in dexamethasone groups. A fixed-effects model was adopted when I2&lt;50% and P&gt;.05; otherwise, the random effects model was adopted.

Pain assessment and analgesic management in patients admitted to intensive care: an Australian and New Zealand point prevalence study

Objective: To describe pain assessment and analgesic management practices in patients in intensive care units (ICUs) in Australia and New Zealand. Design, setting and participants: Prospective, observational, multicentre, single-day point prevalence study conducted in Australian and New Zealand ICUs. Observational data were recorded for all adult patients admitted to an ICU without a neurological, neurosurgical or postoperative cardiac diagnosis. Demographic characteristics and data on pain assessment and analgesic management for a 24-hour period were collected. Main outcome measures: Types of pain assessment tools used and frequency of their use, use of opioid analgesia, use of adjuvant analgesia, and differences in pain assessment and analgesic management between postoperative and non-operative patients. Results: From the 499 patients enrolled from 45 ICUs, pain assessment was performed at least every 4 hours in 56% of patients (277/499), most commonly with a numerical rating scale. Overall, 286 patients (57%) received an opioid on the study day. Of the 181 mechanically ventilated patients, 135 (75%) received an intravenous opioid, with the predominant opioid infusion being fentanyl. The median dose of opioid infusion for ventilated patients was 140 mg oral morphine equivalents. Of the 318 non-ventilated patients, 41 (13%) received patient-controlled analgesia and 76 (24%) received an oral opioid, with the predominant opioid being oxycodone. Paracetamol was administered to 63 ventilated patients (35%) and 164 non-ventilated patients (52%), while 2% of all patients (11/499) received a non-steroidal anti-inflammatory drug. Ketamine infusion and regional analgesia were used in 15 patients (3%) and 17 patients (3%), respectively. Antineuropathic agents (predominantly gabapentinoids) were used in 53 patients (11%). Conclusions: Although a majority of ICU patients were frequently assessed for pain with a validated pain assessment tool, cumulative daily doses of opioids were high, and the use of multimodal adjuvant analgesia was low. Our data on current pain assessment and analgesic management practices may inform further research in this area.

Paracetamol, ibuprofen and dexamethasone for pain treatment after total hip arthroplasty: protocol for the randomised, placebo-controlled, parallel 4-group, blinded, multicentre RECIPE trial

IntroductionMultimodal analgesia with paracetamol, non-steroidal anti-inflammatory drug and glucocorticoid is recommended for hip arthroplasty, but with uncertain effects of the different combinations. We aim to investigate benefit and harm of...