Analgesic Management Research Articles

The anesthetic management and the role of extracorporeal membrane oxygenation for giant mediastinal tumor surgery.

Mediastinal tumors are a remarkably diverse category. They include malignant and benign forms with different rates of disease progression and tissue invasion. Anesthesiologists may encounter significant difficulties in managing patients with giant mediastinal tumors due to the non-negligible occurrence of severe cardiorespiratory collapse. Respiratory complications ensue from the compression of the airways induced by the mediastinal mass: the compressive effects may be exacerbated by positioning or anesthesia induction. Furthermore, the compression or invasion of major vessels may elicit acute cardiovascular collapse. The specter of sudden cardiorespiratory deterioration should lead the anesthesiologist to careful planning: acknowledging clinical and radiological signs that may presage an increased risk of life-threatening complications is of pivotal importance. This review aims to present a strategy for treating patients with mediastinal masses, starting with the pathophysiological elements and moving through preoperative care, intraoperative behavior, and the recovery period. We will also focus on respiratory and cardiovascular issues, emphasizing the need for extracorporeal membrane oxygenation (ECMO) as a rescue and crucial component of the anesthesia strategy. Understanding the physiological alterations after anesthesia induction can aid in identifying and treating potential problems. In addition, we attempted to offer insight into multimodal anesthesia and analgesia management: we emphasize the importance of a thorough preoperative assessment and the need for reviewing extracorporeal support not just a resuscitative strategy but as an integrated component of the perioperative care.

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View.

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

Analgesic Use in Patients during Cardio-Pulmonary Resuscitation.

Cardiopulmonary resuscitation-induced consciousness is a newly recognized phenomenon with an increasing incidence. A return of consciousness during cardiopulmonary resuscitation affects up to 0.9% of cases. Patients may also experience physical pain associated with chest compressions, as most victims of cardiac arrest who are subjected to resuscitative efforts sustain ribs or sternum fractures. A rapid review was carried out from August 2021 to December 2022. Thirty-two articles were included in the rapid review. Of these, eleven studies focused on the return of consciousness during CPR, and twenty-one on CPR-induced chest injuries. A small number of studies that have dealt with the return of consciousness associated with cardiopulmonary resuscitation made it hard to clearly determine how often this occurs. There were more studies that dealt with chest trauma during resuscitation, but no study considered the use of analgesics. Of note, there was no standardized therapeutic approach as far as the use of analgesics and/or sedatives was considered. This is probably due to the lack of guidelines for analgesic management during cardiopulmonary resuscitation and peri-resuscitative period.

Evidence-based guideline for neonatal pain management in China (2023)

Pain disrupts neonatal vital signs and internal environment homeostasis and affects the recovery process, and recurrent pain stimulation is one of the important risk factors for neurodevelopmental disorders and some chronic diseases. In order to standardize pain management practice in neonatal wards in China and effectively prevent and reduce the adverse effects of pain on the physical and mental development of neonates, National Clinical Research Center for Child Health and Diseases (Children's Hospital of Chongqing Medical University) convened a multidisciplinary panel to formulate the evidence-based guideline for neonatal pain management in China (2023 edition) following the principles and methods for the guideline development issued by the World Health Organization. Based on the best evidence and expert consensus, this guideline gives 26 recommendations for nine clinical issues, i.e., the classification and definition of neonatal pain, common sources of pain, pain assessment principles, pain assessment methods, analgesic principle, non-pharmaceutical analgesic methods, pharmaceutical analgesic methods, parental participation in pain management, and recording methods for pain management, so as to provide medical staff with guidance and a decision-making basis for neonatal pain assessment and analgesia management.

ANALGESIA BIAS IN TIBIAL SHAFT FRACTURES: A COMPARISON BETWEEN MAORI AND NON-MAORI

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori.A retrospective cohort study from January 1st, 2015, to December 31st 2020 inclusive. Eligible patients were 16-65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriateNo statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004)Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori.The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area.

Postoperative Outcomes of Analgesic Management with Erector Spine Plane Block at T5 Level in Pediatric Patients Undergoing Cardiac Surgery with Sternotomy: A Cohort Study.

There is limited evidence on the impact of erector spinae plane block (ESPB) as part of multimodal analgesia in pediatric population undergoing cardiac surgery. A retrospective cohort study was conducted in patients under 18 years of age, who underwent cardiac surgery Risk Adjusted classification for Congenital Heart Surgery (RACHS-1) ≤3 by sternotomy. The study aims to evaluate the effect of ESPB as part of multimodal analgesia in pediatric patients undergoing cardiac surgery compared to conventional analgesia (CA) on relevant clinical outcomes: length of hospital stay, length of ICU stay, opioid consumption, time to extubation, mortality, and postoperative complications. The participants included were treated in a reference hospital in Colombia from July 2019 to June 2022. Eighty participants were included, 40 in the ESPB group and 40 in the CA group. There was a significant decrease (Log rank test p = 0.007) in days to length of hospital stay in ESPB group (median 6.5 days (IQR: 4-11)) compared to the CA group (median 10.5 days (IQR: 6-25)). Likewise, there was a higher probability of discharge from the ICU in the ESPB group (HR 1.71 (95% CI: 1.05-2.79)). The ESPB group had lower opioid consumption (p < 0.05). There were no differences in time to extubation, mortality, and postoperative complications. ESPB as part of multimodal analgesia in pediatric patients undergoing cardiac surgery is feasible and associated with shorter hospital length of stay, faster ICU discharge and lower opioid consumption.

A survey of current practices in sedation, analgesia, withdrawal, and delirium management in paediatric cardiac ICUs.

To characterise the current approach to sedation, analgesia, iatrogenic withdrawal syndrome and delirium in paediatric cardiac ICUs. A convenience sample survey of practitioners at institutions participating in the Pediatric Cardiac Critical Care Consortium conducted from September to December 2020. Paediatric cardiac ICUs. Survey responses were received from 33 of 42 institutions contacted. Screening for pain and agitation occurs commonly and frequently. A minority of responding centres (39%) have a written analgesia management protocol/guideline. A minority (42%) of centres have a written protocol for sedation. Screening for withdrawal occurs commonly, although triggers for withdrawal screening vary. Only 42% of respondents have written protocols for withdrawal management. Screening for delirium occurs "always" in 46% of responding centres, "sometimes" in 36% of centres and "never" 18%. Nine participating centres (27%) have written protocols for delirium management. Our survey identified that most responding paediatric cardiac ICUs lack a standardised approach to the management of analgesia, sedation, iatrogenic withdrawal, and delirium. Screening for pain and agitation occurs regularly, while screening for withdrawal occurs fairly frequently, and screening for delirium is notably less consistent. Only a minority of centres use written protocols or guidelines for the management of these problems. We believe that this represents an opportunity to significantly improve patient care within the paediatric cardiac ICU.

Quality indicators in intensive care medicine for Germany - fourth edition 2022.

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Retracted: The Application of the Nurse-Led Sedation and Analgesia Management in ICU after Heart Surgeries.

[This retracts the article DOI: 10.1155/2022/7706172.].

Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review.

Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.

Parietal Infiltration for Postoperative Analgesia

The parietal component of pain occupies an important place in the management of postoperative analgesia. Parietal infiltration is a technique that fits into a concept of multimodal analgesia using several analgesic products simultaneously. This simple and reliable technique makes it possible to reduce the use of opioids and therefore their adverse effects; without increasing the risk of infection. It reduces the length of hospitalization.

The Relationship of Postoperative Pain and Opioid Consumption to Postoperative Delirium After Spine Surgery.

To examine the relationship between postoperative pain and opioid use and the development of postoperative delirium (POD), with attention to the preoperative opioid use status of patients. This was a secondary analysis of data from a prospective observational study of patients (N = 219; ≥70 years old) scheduled to undergo elective spine surgery. Maximal daily pain scores (0-10) and postoperative morphine milligram equivalents per hour (MME/hr) were determined for postoperative days 1-3 (D1-3). POD was assessed by daily in-person interviews using the Confusion Assessment Method and chart review. Patients who reported regular preoperative opioid use (n = 58, 27%) reported significantly greater maximal daily pain scores, despite also requiring greater daily opioids (MME/hr) in the first 3 days after surgery. These patients were also more likely to develop POD. Interestingly, while postoperative pain scores were significantly higher in patients who developed POD, postoperative opioid consumption was not significantly higher in this group. POD was associated with greater postoperative pain, but not with postoperative opioid consumption. While postoperative opioid consumption is often blamed for delirium, these findings suggest that uncontrolled pain may actually be a more important factor, particularly among patients who are opioid tolerant. These findings underscore the importance of employing multimodal perioperative analgesic management, especially among older patients who have a predilection to developing POD and baseline tolerance to opioids.

Early Warning System Triggers In Intensive Care Unit After Receiving Intrathecal Morphine: A Retrospective Analysis

Background: Neuraxial analgesia, including intrathecal morphine(ITM) administration, provides excellent analgesia in the post-abdominal surgery setting. As a corollary, such patients are commonly admitted to HDU/ICU for post-operative monitoring, and as such, bed availability can curtail its use. Reluctance to ward based postoperative care for this cohort is evident. Ward based postoperative care could benefit post-operative analgesic management.

Effect of Postoperative Pain Management after Robot-Assisted Radical Prostatectomy: A Study on Reducing Hospital Length of Stay and Medical Costs Using Japanese Nationwide Database.

Prostate cancer has a high incidence rate. Many articles reported its usefulness with the advent of robotic surgery in 2001. However, epidural analgesia is declining due to the spread of minimally invasive treatment. There have been no studies using nationwide databases on the impact of epidural analgesia use on length of hospital stay and medical costs. Therefore, we used a Japanese national inpatient database from April 2016 to March 2020. The study population included 46,166 patients. We compared a postoperative analgesia management group using epidural analgesia [Epidural Analgesia Group (EA Group): 5,354] and a group not using epidural analgesia [non-Epidural Analgesia Group (non-EA Group): 40,812]. We found significant differences among the two groups regarding the length of stay, days from surgery to discharge, and inpatient cost of surgery to discharge. Hospital length of stay and postoperative hospital stay was statistically shorter in the EA group than in the non-EA group (11.3 ± 2.8 days vs. 12.1 ± 3.1 days, p < 0.001 and 8.9 ± 2.5 days vs. 9.3 ± 2.7 days, p < 0.001), respectively, and medical costs were also significantly lower in the EA group (84,566 JPY vs. 294,277 JPY, p < 0.001). Also, the activities of daily living (ADL) assessment at discharge determined a considerably higher score in the EA group than in the non-EA groups. Epidural analgesia for postoperative pain management largely depends on each medical institution's treatment policy. However, epidural analgesia is declining due to the spread of minimally invasive treatment. Therefore, epidural analgesia should be reconsidered because it can reduce hospital stays and hospitalization costs.

Ultrasound-guided Transversus Abdominis Plane Block for Postoperative Analgesia in Patient Undergoing Inguinal Hernia Repair

Background: The Transversus Abdominis Plane (TAP) block technique is one method for inhibiting abdominal pain stimuli by blocking afferent nerves in the abdominal wall via the Petit triangle. TAP block action is frequently performed as a postoperative procedure, such as in the case of hernia repair. The goal of using ultrasound in TAP blocks is to distribute the anesthetic agent accurately in the appropriate neurovascular plane. Case: A 66-year-old male geriatric patient with an incarcerated right inguinal hernia and a history of Hypertensive Heart Disease (HHD) was seen. The patient complained of right groin pain that spread to the right side of the abdomen. Based on the Electrocardiogram (ECG), atrial fibrillation was identified as slow ventricular response and Left Ventricular Hypertrophy (LVH). Chest X-ray revealed cardiomegaly with LVH configuration. ASA III E was assigned to the patient. Regional Anesthesia Subarachnoid Block (RASAB) was used to perform an emergency hernia repair using a regimen of Bupivacaine heavy 0.5% 7.5 mg with adjuvant Fentanyl 50 g. Bilateral TAP block administration using Ropivacaine regimen 0.25% of the total volume of 30 ml was given as postoperative analgesia management. Hemodynamic monitoring, complications and postoperative pain scale were carried out in the High Care Unit (HCU). Hemodynamically stable, pain scale was 1-2 at 24 hours postoperative and no complications. Conclusion: TAP block is provide an effective and safe anti-pain effect in patients undergoing hernia repair with geriatric comorbidities and a history of HHD, as well as to prevent cardiovascular complications and to speed up postoperative patient mobilization.

Ultrasound-guided modified pectoral plane (PECS II) block versus erector spinae plane (ESP) block for perioperative analgesia of surgical treatment of gynecomastia

BackgroundNerve block reduces anesthetics requirement, allows faster recovery, and reduces postoperative pain. The modified pectoral plane block (PECS II) and the erector spinae plane block (ESP) have been proposed for nerve block in men undergoing breast surgery for gynecomastia.This study aimed to compare the efficacy of PECS II and ESP for perioperative analgesia in men undergoing surgical treatment of gynecomastia.We conducted a randomized clinical trial on 46 males (with ASA I and II, age range from 18 to 25 years) undergoing surgical gynecomastia treatment in a tertiary medical center. Patients were randomly allocated to receive nerve blocks with either PECS II or ESP in addition to the general anesthesia. The postoperative opioid requirement, analgesic doses, pain intensity on the VAS score, hemodynamic parameters throughout the operation, and complications were recorded and compared for both groups.ResultsPECS II group had more favorable outcomes compared to the ESP group, evident by the significantly less total morphine consumption in 24 h (6.09 vs. 14.26 mg, P ≤ 0.001) and the significantly higher effective analgesic time (6.57 vs. 4.91 h, P ≤ 0.001). In addition, there were no intraoperative or postoperative complications recorded in both groups.ConclusionsFor men undergoing elective surgical treatment of gynecomastia, the ultrasound-guided modified PECS II is superior to the ESP in terms of opioid requirement, analgesic doses, and pain intensity.

Use and misuse of opioid after gynecologic surgery.

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

Comparison of the Efficacy between Femoral Nerve Block and Fascia Iliaca Compartment Block for Postoperative Analgesia in Patients after Knee Surgery

Background: Moderate to severe pain develop after knee surgery results prolong hospital stay and delay return to normal daily activities. Various analgesic modalities have been used for postoperative analgesia in patients undergoing knee surgery. Both femoral nerve block (FNB) block and fascia iliaca compartment block (FIB) are used routinely for postoperative pain relief in patients undergoing knee surgery. Objectives: To compare the efficacy of postoperative analgesia of FNB &amp; FIB in postoperative period among patients undergoing knee surgery under sub- arachnoid block. Methods: This Randomized Clinical Trial was performed in Combined Military Hospital (CMH), Dhaka from July 2020 to December 2020. Forty patients scheduled for routine knee surgery under sub-arachnoid block belonging to ASA class I, II and III were included in the study and randomly divided into two groups with 20 patients in each group. At the end of surgery, In Group A (n= 20) femoral nerve block was employed &amp; in Group B (n=20) fascia iliaca compartment block was employed. Results: Significant relief of pain occurred in recovery room in group B than group A (3.67±0.802 vs 4.3±0.877; p&lt;0.05). This improvement was noticed in group B at 6 and 24 hours follow up (p&lt;0.05 in all follow up). Post-operative analgesic consumptions was also lower in group B at 1, 12 &amp; 24 hours follow up (p&lt;0.05 in all follow up). Demographic characteristics were similar across the two groups in terms of age, sex, BMI and ASA grading (p&gt;0.05 in all cases). No significant difference was noted in both pre-operative, post-operative and recovery room heart rate (p&gt;0.05) and mean arterial pressure (p&gt;0.05). Complication was similar in both groups. Conclusion: Fascia iliaca compartment block (FIB) for management of post-operative analgesia in knee surgery is more effective than femoral nerve block (FNB).

Effectiveness and safety of path-based analgesic regimens designed by clinical pharmacists based on the type of biliary and pancreatic surgery.

As the incidence of postoperative pain in patients with biliary and pancreatic diseases has gradually increased, how to control postoperative pain has received increasing research attention. By reading pain management guidelines and multidisciplinary communication and cooperation, clinical pharmacists designed multi-mode analgesia regimens based on surgical types, in order to provide strong evidence for the effectiveness and safety of postoperative analgesia regimens and better serve patients. Data from biliary or pancreatic surgery performed at Nanjing Drum Tower Hospital from 2019 to 2021 were collected. Take October 2020 as the time point to compare the outcomes before and after the implementation of the path-based postoperative analgesic regimens. The primary outcomes were NRS pain scores, sleep quality, and incidence of adverse reactions. Length of stay was a secondary outcome. A total of 268 and 239 patients were enrolled in the study and control groups, respectively. Four path-based postoperative analgesic management regimens significantly reduced patients' static and dynamic NRS scores in the 24 h (p < 0.05). The patients' sleep quality were better than controls (p > 0.05). The incidence of adverse reactions and the length of stay in the study group were numerically lower than controls. Moderate analysis indicated that four analgesia regimens are more precise and better meet actual clinical needs. Effective and safe postoperative pain management is particularly important for clinical purposes. Path-based postoperative analgesia regimens based on different types of surgery overcome the disadvantages of overly broad and generalized traditional guidelines, which play an important role in providing personalized and precise clinical services. Further, study findings provide evidence that four path-based analgesic regimens can reduce postoperative pain and reduce the length of hospital stay, which may provide a better direction for clinical postoperative pain management.

Electroencephalogram-based prediction and detection of responsiveness to noxious stimulation in critical care patients: a retrospective single-centre analysis

BackgroundMonitoring of pain and nociception in critical care patients unable to self-report pain remains a challenge, as clinical signs are neither sensitive nor specific. Available technical approaches are limited by various constraints. We investigated the electroencephalogram (EEG) for correlates that precede or coincide with behavioural nociceptive responses to noxious stimulation. MethodsIn this retrospective study, we analysed frontal EEG recordings of 64 critical care patients who were tracheally intubated and ventilated before, during, and after tracheal suctioning. We investigated EEG power bands for correlates preceding or coinciding with behavioural responses (Behavioural Pain Scale ≥7). We applied the Mann–Whitney U-test to calculate corresponding P-values. ResultsStrong behavioural responses were preceded by higher normalised power in the 2.5–5 Hz band (+17.1%; P<0.001) and lower normalised power in the 0.1–1.5 Hz band (–10.5%; P=0.029). After the intervention, strong behavioural responses were associated with higher normalised EEG power in the 2.5–5 Hz band (+16.6%; P=0.021) and lower normalised power in the 8–12 Hz band (–51.2%; P=0.037) ConclusionsWe observed correlates in EEG band power that precede and coincide with behavioural responses to noxious stimulation. Based on previous findings, some of the power bands could be linked to processing of nociception, arousal, or sedation effects. The power bands more closely related to nociception and arousal could be used to improve monitoring of nociception and to optimise analgesic management in critical care patients. Clinical trial registrationDRKS00011206.