Adjuvant Analgesics Research Articles

Pediatric palliative care: Competency and educational needs assessment in pediatricians of a developing country

Pediatric Palliative Care (PPC) is a nascent subspecialty that aims on achieving the best possible quality of life for children with life-threatening illnesses. To attain this goal in a developing country, Pediatricians require adequate knowledge and skill in this subject. Assessment of competency and educational needs in Pediatricians is the first step towards this aim. A multi-center, self-reported, cross-sectional, online survey was conducted among Pediatric residents and junior staff pediatricians from various teaching hospitals in Pakistan. Data were analyzed in terms of descriptive statistics using SPSS 16. Total 284 Pediatric residents and junior staff pediatricians from 4 different training programs and 13 different teaching hospitals of Punjab, Pakistan recorded their responses. The mean age of respondents was 30.19 years (+2.67 SD) with a male-to-female ratio of 1:1.2. Regarding self-assessment of competency in end-of-life clinical skills, low or below average competence (Mean < 2.55) was reported in assessment and management of terminal delirium, agitation, and anxiety; use of adjuvant analgesics, discussing treatment withdrawal, use of parenteral opioid analgesics, and developing family-centered goals of care. Improved competence was observed with the increasing years of training/experience. Regarding interest(s) in learning about end-of-life clinical topics, all of the 10 topics included in the survey reached a significant level of interest (Mean > 2.5) while the top 3 recommended topics were: Pain assessment and management, assessment and management of terminal delirium, agitation, anxiety, and assessment and management of terminal dyspnea. Pediatricians in a developing country are eager to learn more about PPC but significant gaps exist in current training in PPC in our country that need to be bridged.

The opioid epidemic from the acute care hospital front line.

Prescription opioid use has risen steeply for over two decades, driven primarily by advocacy for better management of chronic non-cancer pain, but also by poor opioid stewardship in the management of acute pain. Inappropriate prescribing, among other things, contributed to the opioid 'epidemic' and striking increases in patient harm. It has also seen a greater proportion of opioid-tolerant patients presenting to acute care hospitals. Effective and safe management of acute pain in opioid-tolerant patients can be challenging, with higher risks of opioid-induced ventilatory impairment and persistent post-discharge opioid use compared with opioid-naive patients. There are also increased risks of some less well known adverse postoperative outcomes including infection, earlier revision rates after major joint arthroplasty and spinal fusion, longer hospital stays, higher re-admission rates and increased healthcare costs. Increasingly, opioid-free/opioid-sparing techniques have been advocated as ways to reduce patient harm. However, good evidence for these remains lacking and opioids will continue to play an important role in the management of acute pain in many patients.Better opioid stewardship with consideration of preoperative opioid weaning in some patients, assessment of patient function rather than relying on pain scores alone to assess adequacy of analgesia, prescription of immediate release opioids only and evidence-based use of analgesic adjuvants are important. Post-discharge opioid prescribing should be contingent on an assessment of patient risk, with short-term only use of opioids. In partnership with pharmacists, nursing staff, other medical specialists, general practitioners and patients, anaesthetists remain ideally positioned to be involved in opioid stewardship in the acute care setting.

Ketamine as a Nonopioid Option for Pain Management

Practice Pointers| August 01 2021 Ketamine as a Nonopioid Option for Pain Management Crit Care Nurse (2021) 41 (4): 92. https://doi.org/10.4037/ccn2021903 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Cite Icon Cite Get Permissions Citation Ketamine as a Nonopioid Option for Pain Management. Crit Care Nurse 1 August 2021; 41 (4): 92. doi: https://doi.org/10.4037/ccn2021903 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentCritical Care Nurse Search Advanced Search Morphine is the standard of care in the treatment of pain, but if a patient has allergies or high opioid needs, ketamine is a great adjuvant analgesic. Not really. The hallucinations associated with ketamine could be confused with mental status changes in this fragile population. There are no specific populations that should avoid ketamine. Rather, the decision to avoid ketamine use is more individual and patient specific—such as in patients with increased intracranial pressure, cardiovascular disease, end-stage liver disease, or a history of psychosis. Ketamine is contraindicated for patients with increased intracranial pressure. In addition, if the patient has a traumatic brain injury, administration of ketamine can make assessments challenging. Yes, it is very effective and appropriate for patients with chronic pain who have been receiving opioid therapy for a while. Consider ketamine for short-term use, as it can “reset” opioid receptor sites. Such as reset will allow the patient... You do not currently have access to this content.

Effect of magnesium sulfate with ketamine infusions on intraoperative and postoperative analgesia in cancer breast surgeries: a randomized double-blind trial

BackgroundOpioids are the cornerstone in managing postoperative pain; however, they have many side effects. Ketamine and Magnesium (Mg) are NMDA receptor antagonists used as adjuvant analgesics to decrease postoperative opioid consumption. ObjectiveWe assumed that adding Mg to ketamine infusion can improve the intraoperative and postoperative analgesic efficacy of ketamine infusion alone in cancer breast surgeries. MethodsNinety patients aged between 18 and 65 years and undergoing elective cancer breast surgery were included in this prospective randomized, double-blind study. Group K received ketamine 0.5.ßmg.kg...1 bolus then 0.12.ßmg.kg...1.h...1 infusion for the first 24.ßhours postoperatively. Group KM: received ketamine 0.5.ßmg.kg...1 and Mg sulfate 50.ßmg.kg...1, then ketamine 0.12.ßmg.kg...1.h...1 and Mg sulfate 8.ßmg.kg...1.h...1 infusions for the first 24.ßhours postoperative. The primary outcome was the morphine consumption in the first 24.ßhours postoperative, while the secondary outcomes were: intraoperative fentanyl consumption, NRS, side effects, and chronic postoperative pain. ResultsGroup KM had less postoperative opioid consumption (14.12.ß...ß5.11.ßmg) than Group K (19.43.ß...ß6.8.ßmg). Also, Group KM had less intraoperative fentanyl consumption. Both groups were similar in postoperative NRS scores, the incidence of side effects related to opioids, and chronic neuropathic pain. ConclusionAdding Mg to ketamine infusion can safely improve intraoperative and postoperative analgesia with opioid-sparing effect in cancer breast surgery.

Pain-related Prescribing Patterns and Associated Factor in Breast Cancer Patients

Other SectionsAbstractBody대상 및 방법연구 결과고 찰결 론감사의 말씀이해상충TableReferenceBackground: With an increase in the number of breast cancer survivors, greater importance is attached to health-related quality of life, particularly pain and symptom control. This study aimed to identify the factors that are associated with pain in cancer patients based on the patterns of prescribing opioid, non-opioid, and adjuvant analgesics. Methods: This analysis included new patients who had developed breast cancer between 2003 and 2012. The degree of pain was analyzed based on the socio-demographic (age, income quintile, number of hospitalizations, and duration of disease), indicator (Body Mass Index; BMI, Charlson Comorbidity Index; CCI, Cumulative Analgesic Consumption Score; CACS), operation (mastectomy, lymph node dissection), and therapy (chemotherapy, radiation therapy), as well as complication-related variable (lymphedema). Results: As for the patterns of prescribing analgesics by stages, non-opioid and opioid analgesics constituted 30.7 and 69.3%, respectively. The mean value and variance of CACS were 5.596 and 12.567, respectively. The factors that significantly affected the degree of pain were age (≥50; IRR: 1.848, 95% CI 1.564- 2.184, p=0.000), income quintile (IRR: 0.964, 95% CI 0.938-0.991, p=0.008), BMI (≥ 25; IRR: 1.479, 95% CI 1.222-1.795, p= 0.000), CCI (≥ 4; IRR: 1.649, 95% CI 1.344-2.036, p=0.000), and lymphedema (yes; IRR: 1.267, 95% CI 1.006-1.610, p=0.047). Conclusions: It is necessary to develop systematic and comprehensive pain control measures to improve the quality of life for breast cancer survivors, especially for those who are 50 years or older, lie in the lower-income quintile, have BMI of ≥25 and CCI score ≥ 4, or have lymphedema.Keywords : Breast neoplasms, cancer pain, comorbidity, analgesics, prescriptions

Effects of Dexmedetomidine as an Analgesic Adjuvant for Surgery of Femur Fracture: A Systematic Review and Meta-Analysis

Patients who undergo surgery of femur fracture suffer the excruciating pain. Dexmedetomidine (DEX) is a unique α2-adrenergic receptor agonist with sedative and analgesic properties, whose efficacy and safety are still unclear for surgery of femur fracture. Randomized controlled trials comparing the effects of addition of DEX to general or local anesthesia in surgery of femur fracture were searched from MEDLINE, EMBASE, and the Cochrane Library database. Patients who received DEX infusion had a significant longer time to rescue analgesia compared with those without DEX coadministration. DEX treatment seemed to reduce the visual analog score; however, the significance did not reach any statistical difference. DEX as an analgesic adjuvant did not reduce the onset of sensory block time, shorten the time to achieve maximum sensory block level, and provide a longer duration of sensory block. The difference in mean sedation scores between 2 groups was not statistically significant. As for adverse effects, DEX therapy significantly increased the rate of hypotension. In conclusion, dexmedetomidine as a local anesthetic adjuvant in femur fracture surgery had a longer duration of rescue analgesia. However, the incidence of hypotension was markedly increased in these patients. It was worth noting that the evidence was of low to moderate quality.

S-ketamine in patient-controlled analgesia reduces opioid consumption in a dose-dependent manner after major lumbar fusion surgery: A randomized, double-blind, placebo-controlled clinical trial.

BackgroundSpinal fusion surgery causes severe pain. Strong opioids, commonly used as postoperative analgesics, may have unwanted side effects. S-ketamine may be an effective analgesic adjuvant in opioid patient-controlled analgesia (PCA). However, the optimal adjunct S-ketamine dose to reduce postoperative opioid consumption is still unknown.MethodsWe randomized 107 patients at two tertiary hospitals in a double-blinded, placebo-controlled clinical trial of adults undergoing major lumbar spinal fusion surgery. Patients were randomly allocated to four groups in order to compare the effects of three different doses of adjunct S-ketamine (0.25, 0.5, and 0.75 mg ml-1) or placebo on postoperative analgesia in oxycodone PCA. Study drugs were administered for 24 hours postoperative after which oxycodone-PCA was continued for further 48 hours. Our primary outcome was cumulative oxycodone consumption at 24 hours after surgery.ResultsOf the 100 patients analyzed, patients receiving 0.75 mg ml-1 S-ketamine in oxycodone PCA needed 25% less oxycodone at 24 h postoperatively (61.2 mg) compared with patients receiving 0.5 mg ml-1 (74.7 mg) or 0.25 mg ml-1 (74.1 mg) S-ketamine in oxycodone or oxycodone alone (81.9 mg) (mean difference: -20.6 mg; 95% confidence interval [CI]: -41 to -0.20; P = 0.048). A beneficial effect in mean change of pain intensity at rest was seen in the group receiving 0.75 mg ml-1 S-ketamine in oxycodone PCA compared with patients receiving lower ketamine doses or oxycodone alone (standardized effect size: 0.17, 95% CI: 0.013–0.32, P = 0.033). The occurrence of adverse events was similar among the groups.ConclusionsOxycodone PCA containing S-ketamine as an adjunct at a ratio of 1: 0.75 decreased cumulative oxycodone consumption at 24 h after major lumbar spinal fusion surgery without additional adverse effects.

English

BACKGROUND Post caesarean section pain requires effective analgesia. Effective analgesia is integral to improvement of quality and patient care among lower segment caesarean section (LSCS) patients. Magnesium, an N-methyl-D-aspartate receptor antagonist along with calcium-channel blocker, has previously been investigated for its analgesic properties. But there is scanty previous literature available for intramuscular magnesium sulphate in the analgesic role in post caesarean mothers. The purpose of this study was to evaluate the effect of existing MgSO4 regimens (among severe pregnancy induced hypertension patients, excluding eclampsia) during early 1st 24 hours’ postoperative analgesic requirements in caesarean section patients comparing to only analgesic group. METHODS It is a retrospective observational study, conducted from January 2019 to June 2020. Patients were randomly selected, normal patients as control = 50 who got post-operative inj. diclofenac 75 mg IM twice a day and rescue analgesia inj. diclofenac 75 mg IM. Test sample comprised of 50 randomly selected severe pregnancy induced hypertension (PIH) patients who got prophylactic inj. magnesium sulphate by Pritchard regimen for 24 hrs. post delivery with 4 gm 20 % inj. magnesium sulphate intravenous with 10 gm 50 % intramuscular in both buttocks as loading dose followed by 5 gm 50 % inj. magnesium sulphate intramuscular 4th hourly for 24 hrs. along with inj. diclofenac 75 mg IM twice a day. Visual analogue scale for pain was noted among both the groups, and were compared for the effect of analgesics in the study groups. RESULTS There was a decrease in analgesic consumption and immediate post-operative pain in the group receiving MgSO4 with analgesic (inj. diclofenac 75 mg), in comparison to control group of inj. diclofenac 75 mg. (P &lt; 0.0001). CONCLUSIONS There was a decrease in analgesic consumption in the group receiving MgSO4 plus analgesic, in comparison to control group (analgesic group). Pain severity assessment 2, 6, 12 and 24 hours post operatively showed that there was a statistically significant decrease in pain scores between the study and the control groups (P &lt; 0.0001). It established the role of magnesium sulphate as an adjuvant analgesic along with diclofenac or other traditionally used pain medications among the post caesarean mothers in early post-operative period. KEYWORDS Analgesia, Pregnancy, Post-Operative Analgesia, Magnesium Sulphate, Lower Segment Caesarean Section (LSCS), Pain Relief, Obstetrics

Subcutaneous Lidocaine Infusion for Complex Cancer Pain: A Retrospective Review

This retrospective review assesses the safety and efficacy of subcutaneous lidocaine infusions for complex cancer pain, in a specialist palliative care unit. A retrospective chart review was undertaken of 18 infusions over a 2-year period. Data collected included patient demographics, use of adjuvant analgesics, methadone use and opioid requirements (as oral morphine equivalent daily dose, oMEDD) at three time periods: 24 hours prior to starting infusion, 24 hours after starting infusion and 24 hours after stopping infusion. Data was collected on infusion characteristics, adverse events and the patient’s perception of lidocaine efficacy. Eighteen infusions were analyzed; all patients had metastatic cancer with 83.3% having stage IV disease. The majority of patients were prescribed three or more adjuvant analgesics, in addition, methadone was prescribed in 16 oMEDD use both 24 hours after starting, and 24 hours after stopping the lidocaine infusions. Events were reported in three out of 18 infusions, only one minor adverse event was attributed to lidocaine. Thirteen out of 18 infusions were perceived, by patients, to be effective for pain. This retrospective review has shown that a subcutaneous lidocaine infusion is a safe and effective means of managing complex cancer pain in a specialist palliative care unit.

Dexmedetomidine upregulates microRNA-185 to suppress ovarian cancer growth via inhibiting the SOX9/Wnt/β-catenin signaling pathway

ABSTRACT Dexmedetomidine (DEX) could serve as an adjuvant analgesic during cancer therapies. Abnormal expression of microRNAs (miRNAs) could lead to cancer development. This study was aimed to explore the roles of DEX in ovarian cancer (OC) development. OC cell lines SKOV3 and HO-8910 were treated with DEX, after which OC development and the miR-185, SOX9, and Wnt/β-catenin pathway were measured. DEX-treated HO-8910 cells were transfected with miR-185 mimic, miR-185 antisense or miR-185 antisense + silenced SOX9 to further measure the OC cell growth. The target relation between miR-185 and SOX9 was identified, and SOX9 and Wnt/β-catenin pathway were protein levels detected after miR-185 transfection. The role of miR-185 in OC in vivo was also measured. Our study found DEX had a dose-dependent inhibition on OC growth, and DEX promoted miR-185 but suppressed SOX9 expression in OC cells. miR-185 targeted SOX9. After interfering with miR-185 expression, HO-8910 cell proliferation, invasion, migration, and apoptosis were affected. SOX9 knockdown repressed OC development and Wnt/β-catenin pathway. The volume, weight, positive rate of Ki67, CyclinD1, p53 and the degree of tumor necrosis were affected by miR-185 expression. This study demonstrated that DEX could inhibit OC development via upregulating miR-185 expression and inactivating the SOX9/Wnt/β-catenin signaling pathway.

Prescribing of adjuvant analgesics among patients in primary care and specialized pain clinic

IntroductionChronic low back pain (CLBP) is one of the most resistant pain conditions and is often combined with psychoemotional disorders [1].ObjectivesTo analyze the frequency of prescribing adjuvant analgesics among patients with CLBP by specialists of the outpatient department and specialized pain clinic.MethodsThe prospective study included 269 patients (group 1) with CLBP treated in an outpatient department and 253 patients (group 2) of specialized pain clinic. We analyzed gender, age, duration, and severity of pain (using the visual analogue scale-VAS), frequency of prescribing anticonvulsants and antidepressants, as well as their combination in both groups. The data were analyzed with IBM SPSS Statistics.ResultsAmong the patients of both groups, women predominated (65.3% in group 1 and 57.2% in group 2). The average age was 61.8±14.5 and 58.9±12.7, in the first and second groups, respectively. The disease duration was longer in group 2 (6.8±3.9 years, and 4.5 ± 2.7 in group 1, p&lt;0.05). Pain intensity was comparable in both groups (4.3±2.8 and 5.1±2.5, p&lt;0.067 on VAS). Antidepressants there were prescribed 16.1% and 52.9%, p&lt;0.05, anticonvulsants - 18.8% and 33.2 %, p&lt;0.05, their combination - 2.2% and 13.8%, p&lt;0.05 in the first and second groups, respectively.ConclusionsAdjuvant analgesics are more often prescribed to patients of specialized pain clinics. It may be associated with more severe descriptions of chronic pain syndrome, as well as insufficient awareness of modern approaches to the management in this category of patients by specialists in primary health care.

Pudendal nerve block as a countermeasure to postoperative chronic pain after removal of Bartholin's cyst

The chronic pain syndrome is a serious post-operative complication. In our practice we have discovered a certain percent of neuralgia of the pudendal nerve in vaginal surgery – more precisely in Bartholin’s cyst removal. As a highly efficient countermeasure we propose a nerve block of the pudendal nerve. We have performed a retrospective study of patients who underwent a Bartholin’s cyst removal in the span of 1 year from January 1st 2019 to December 31st 2019. All of the patients included are diagnosed with chronic pain in the area innervated from the pudendal nerve. In all of the patients a pudendal nerve block with local anesthetic was performed under the guidance of ultrasound. A total of 11 patients were included in the study. There was a time interval between the Bartholin’s cyst removal surgery and the performance of the nerve block. All patients expressed moderate pain before the procedure. In only 1 case a repeat of the nerve block was imposed. There were no short- or long-term complications of any kind. The patients have been followed-up in the duration of 1 year and 100% has been reported. Accurate and precise pain assessment is vital of the diagnosing and subsequent treatment of the chronic pain syndrome. There are many ways of treating the syndrome both conventional (non-steroidal anti-inflammatory drugs, opioids, topical analgesics and adjuvant analgesics) and unconventional. Chronic pain syndrome is an important multilayered problem that requires personal approach. The nerve block of the pudendal nerve is a highly efficient method of coping with that disease.

Pregabalin abuse and toxicity and related factors

Pregabalin is one of a group of gabapentinoids approved by the Food and Drug Administration (FDA) in 2004. It is a capsule medication taken by mouth that is used for the treatment of neuropathic pain. It is a structural analogue of the neurotransmitter gamma-aminobutyric acid (GABA), and it appears to have a spectrum of benefits and harms similar to those of other adjuvant analgesics used to treat neuropathic pain. The most common side effects mentioned in peripheral neuropathy studies are dizziness and somnolence. Pregabalin could cause liver toxicity by increasing the levels of liver enzymes. It can potentially cause vasodilatation and fluid retention in the heart and blood vessels. It may also lead to addiction. The use of Pregabalin is common among patients with a history of substance abuse and psychoactive drug dependence, as euphoria is one of its main side effects. However, abrupt discontinuation from using Pregabalin may cause nausea, insomnia, or headache. The present review evaluates the significant impact of Pregabalin toxicity on liver and heart in patients and misusers. Keywords: Pregabalin, liver toxicity, alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase (CK), heart failure, addiction.

Profile of Ear Nose Throat and Head Neck Inpatient Care Undergoing Shortwave Diathermy in a Tertiary Care Centre of Punjab -A 3.5 Year Study

Background: Short wave diathermy acts as magic potion in many Otorhinolaryngology and head neckpathologies where either conservative therapeutic modality or surgical intervention has been undertaken.The profile of subjects who underwent short wave diathermy in a 3.5 year period is included.Materials and Methods: 101 subjects undergoing short wave diathermy in the Otorhinolaryngology andPhysiotherapy services of a tertiary care centre of Punjab were analyzed during a period of 3.5 years. Thesubjects were analyzed for their demographic profile ,gender profile and seasonal variation over 3.5 years .Results: Maximum patients 55.44%(56 patients) underwent shortwave diathermy were in the middleage group (21-60 years). Males 52.47% (53 patients) outnumbered the females 47.52% (48 patients) whounderwent shortwave diathermy.In the age group 21-60 years, there were maximum females 57.14%(32patients) where the male patients were comparatively less i.e. 42.85% (24 patients). Most significantdifference was seen in above 60 age group where males 73.91%(17patients) outnumbered females 26.08%(6patients).Conclusion: Short wave diathermy is an effective pain therapy for inflammations of ear,nasal cavity andmaxillofacial region , it reduces the dose and duration of adjuvant oral analgesics.

Ultrasound guided Thoracic Paravertebral block for postoperative analgesia after thoracotomy, single level or multiple levels, does it matter?

ABSTRACT Adequate postoperative pain control may help to minimize postoperative pulmonary complications by enabling earlier ambulation and improving the patient’s ability to take deep breaths. Thoracic paravertebral block (TPVB) is a compartment block; success relies on spread of injected local anesthetic (LA) within the paravertebral space. This block anesthetizes spinal nerves. Patients and methods ; The patients were divided into two group, In Group I: T5 was defined using high frequency linear probe and the corresponding paravertebral space, a Total of 20 ml of Bupivacine 0.25% were injected. In Group II: T4, T5, T6 and T7 were confirmed and 5 ml of of Bupivacine 0.25% were injected in each. 1 ug/kg of fentanyl up to a total of 200 ug and Paracetamol 1 gm were given whenever there is a dramatic change in the hemodynamics with surgical stimulus. At the end, the Pain score were recorded as well as 6 hr, later and the analgesic given. no difference in the median for pain score among the patients 1(1.5) vs 1(1.3) for group I and II respectively), there was a significant reduction in the adjuvant analgesic in group II. 6 hr postoperatively, the median was 5(2.7) vs 2(1.9) only for group II, with a significant statistical reduction in the intensity of pain and the use of postoperative analgesic among the group II. Conclusion ; Multiple injection in paravertebral block is more efficient in controlling pain rather than single level injection.

Intranasal oxytocin as a treatment for chronic pelvic pain: A randomized controlled feasibility study.

To investigate the effect of intranasal oxytocin on chronic pelvic pain in a randomized, double-blind, within-subject crossover trial. Aims included: (1) determine intranasal oxytocin's effect on pain intensity and pain interference relative to placebo; (2) assess feasibility and acceptability. Women with chronic pelvic pain were recruited from chronic pain and gynecology clinics between September 2017 and December 2018. Pain was recorded at pre-trial screening, and while administering intranasal oxytocin and placebo. Pain and pain-related interference were measured using the Brief Pain Inventory - Short Form. Feasibility and acceptability were measured using validated measures and interviews. Twenty-one women were randomized with sufficient data available from 12 to permit analyses. Relative to placebo, a 2-week course of oxytocin administration resulted in improvement in pain severity with no effect on pain-related interference. This effect was driven by four women who demonstrated a minimal clinically significant improvement in pain following intranasal oxytocin (no women met this threshold for placebo). Adherence to dosing was excellent and occurrence of adverse effects did not differ between oxytocin and placebo. Intranasal oxytocin may represent an adjuvant analgesic that could result in a minimal clinically significant improvement in pain among one in three women with chronic pelvic pain. Registration: ClinicalTrials.gov (Registration# NCT02888574).

Application of Midazolam Injection in Patients with Intraoperative Nerve Block Anesthesia and Sedation Assisted by Imaging Guidance

In the present study, we explored the clinical effect of midazolam as an adjuvant analgesic and tranquilizer after brachial plexus block anesthesia with the aid of imaging guidance. We selected 106 patients who had undergone elective unilateral upper extremity surgery from January 2017 to December 2019 and randomly divided them into groups A and B, with 53 cases in each group. All the patients had undergone brachial plexus block anesthesia. Group A received imidazole-assisted sedation, and group B received fentanyl plus midazolam-assisted sedation. Under ultrasound-guided intermuscular sulcus brachial plexus block, we observed and recorded the ultrasound anatomical images before injection, including the distance from the lower edge of the upper, middle, and lower trunk of the forearm brachial plexus to the skin. We also recorded the anesthesia and operation times, effects of the anesthetic block, and incidence of adverse reactions. The distance from the lower edge of each nerve trunk to the skin averaged 1.002 cm for the upper stem, 1.598 cm for the middle stem, and 2.26 cm for the lower stem. The average anesthesia procedure time was 3 minutes, 56 seconds and was within 3-5 minutes for 92% of the procedures. The anesthesia effect was excellent, good, and poor in 81%, 11%, and 6%, respectively, and ineffective for 2% and effective for 92%. The ultrasound-guided inferior intermuscular sulcus approach for brachial plexus block is suitable for unilateral upper extremity radial hand surgery. For surgery involving the upper extremity ulnar hand side, a larger dose (concentration) of local anesthetic should be used within a safe range and/or an additional ulnar nerve block might be necessary. Midazolam adjuvant medication can have a good sedative and amnestic effect in brachial plexus block anesthesia, helping to reduce pain and inhibit the increase in stress levels.

The Benefits of Olanzapine in Palliating Symptoms.

Olanzapine has become a major drug in the management of chemotherapy-induced nausea and vomiting as a prophylactic agent. In addition, a recent randomized trial has demonstrated its benefits in treating nausea and vomiting associated with advanced cancer. The added benefit to olanzapine is that it also stimulates appetite. As a result, since it treats multiple symptoms associated with advanced cancer, it is likely to become the antiemetic of choice in palliative care at least in the USA. The added benefit of treating insomnia and the avoidance of benzodiazepines should place olanzapine in at the top of the list of drugs to use for patients who do complain of insomnia. There is no good evidence that it potentiates the respiratory depression of opioids unlike benzodiazepines. The evidence is weak that olanzapine in as an adjuvant analgesic. Hopefully, future trials will explore this in greater depth. The benefits of adding olanzapine to potent opioids are that it may reduce craving, drug cues, and opioid misuse. Other symptoms like anxiety and depression may be addressed by the addition of olanzapine to standard antidepressants.

Correlation of distance from skin to lumbar epidural space with age and height of patients

Background: Epidural block is a popular and versatile procedure with applications as sole anaesthetic, as an analgesic adjuvant to general anaesthesia and for post-operative analgesia in procedures involving lower limbs, perineum, pelvis, abdomen and thorax. However, success of the epidural technique depends upon the correct identification of epidural space. The knowledge of distance from skin to epidural space can help in better identification of epidural space and epidural catheter placement with fewer incidences of complications. We conducted a study to find the distance from skin to the epidural space and its correlation with patient height and age to improve the success rate. Methods: Seventy-four patients scheduled to undergo lower lumbar surgeries where epidural block was required as anaesthetic or analgesic, were included in the study. These patients were randomly divided into four different groups of 37 patients each according to their age (group A and group B) and height (group C and group D). In these patient’s epidural block was given by standard technique according to the need of surgery and epidural depth measured. Obtained results were compared among group A, B and group C, D depending on their age and height respectively. Results: In group A (age 20-30 years), mean epidural depth was 3.96±0.4 cm while in group B (age 30-40 years) mean epidural depth was 4.05±0.5 centimeters. In group C (height 155-169 cm) mean epidural depth was 3.88±0.4 centimeters while it was 4.13±0.5 centimeters in group D (height 170-184 cm).Conclusions: There was increase in epidural depth with increase in height of patients but there was no correlation between age of patients and epidural depth.

B vitamins and nonsteroidal anti-inflammatory drugs: the efficacy of the combination for nonspecific back pain

Back pain significantly affects quality of life in patients. Therapy for acute and chronic nonspecific back pain (NBS) includes non-drug and drug treatments. The non-drug treatment includes educational conversations with a patient, recommendations to maintain an active lifestyle, therapeutic exercises, behavioral and cognitive-behavioral therapy, and mindfulness. Manual therapy and injections of anesthetics into the area of tender joints may be prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used for drug treatment of acute and chronic NBS. Antidepressants may be prescribed for chronic pain and depression symptoms. B vitamins (thiamine, pyridoxine, and cyanocobalamin) can be considered as adjuvant analgesics in NBS. The results of animal experimental studies have shown that B vitamins at high doses have analgesic and anti-inflammatory effects. Clinical studies, a systematic review, and a meta-analysis published in 2020 demonstrated the safety and advantages of combination therapy with NSAIDs and B vitamins over NSAID monotherapy in the treatment of acute NBS and exacerbations of chronic NBS. The addition of B vitamins to NSAIDs can reduce the duration of treatment by 2 times. By reducing the duration of pharmacotherapy, the risk of adverse reactions to NSAIDs decreases and the patient returns to daily activities more quickly. It is advisable to conduct further, larger studies of combined pharmacotherapy for NBS.