Practice Of Pain Medicine Research Articles

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.

Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.

The legacy of Dr Earl Russell

Dr Earl Russell (1920-2008) was a Canadian anesthetist and pain specialist who spent the majority of his career as a Western University faculty member and a pain physician in Southwestern Ontario. Dr Russell obtained his medical degree at Western, graduating in the class of 1950, and went on to serve in the Korean War as a medical officer. It was in Korea that he began developing a keen interest in pain medicine, using self-taught anesthesia skills to help soldiers suffering from frostbite. He returned to Canada and focused the rest of his career on the practice and advancement of pain medicine, and endowed the Earl Russell Chair in Pain Management in order to fund future research and education in the field. This article highlights the importance of his contributions to the field, in particular through his creation of the Earl Russell Chair, and how this led to the first Pain Medicine residency program in Canada at Western University.

The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017.

The American Society of Regional Anesthesia and Pain Medicine's Third Practice Advisory on local anesthetic systemic toxicity is an interim update from its 2010 advisory. The advisory focuses on new information regarding the mechanisms of lipid resuscitation, updated frequency estimates, the preventative role of ultrasound guidance, changes to case presentation patterns, and limited information related to local infiltration anesthesia and liposomal bupivacaine. In addition to emerging information, the advisory updates recommendations pertaining to prevention, recognition, and treatment of local anesthetic systemic toxicity. WHAT'S NEW IN THIS UPDATE?: This interim update summarizes recent scientific findings that have enhanced our understanding of the mechanisms that lead to lipid emulsion reversal of LAST, including rapid partitioning, direct inotropy, and post-conditioning. Since the previous practice advisory, epidemiological data have emerged that suggest a lower frequency of LAST as reported by single institutions and some registries, nevertheless a considerable number of events still occur within the general community. Contemporary case reports suggest a trend toward delayed presentation, which may mirror the increased use of ultrasound guidance (fewer intravascular injections), local infiltration techniques (slower systemic uptake), and continuous local anesthetic infusions. Small patient size and sarcopenia are additional factors that increase potential risk for LAST. An increasing number of reported events occur outside of the traditional hospital setting and involve non-anesthesiologists.

Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management.

As newer pharmacologic and procedural interventions, technology, and data on outcomes in pain management are becoming available, effective acute pain management will require a dedicated Acute Pain Service (APS) to help determine the most optimal pain management plan for the patients. Goals for pain management must take into consideration the side effect profile of drugs and potential complications of procedural interventions. Multiple objective optimization is the combination of multiple different objectives for acute pain management. Simple use of opioids, for example, can reduce all pain to minimal levels, but at what cost to the patient, the medical system, and to public health as a whole? Many models for APS exist based on personnel's skills, knowledge and experience, but effective use of an APS will also require allocation of time, space, financial, and personnel resources with clear objectives and a feedback mechanism to guide changes to acute pain medicine practices to meet the constantly evolving medical field. Physician-based practices have the advantage of developing protocols for the management of low-variability, high-occurrence scenarios in addition to tailoring care to individual patients with high-variability, low-occurrence scenarios. Frequent feedback and data collection/assessment on patient outcomes is essential in evaluating the efficacy of the Acute Pain Service's intervention in improving patient outcomes in the acute and perioperative setting.

Acupuncture for chronic pain: an update and critical overview.

Acupuncture is now recommended for several chronic pain conditions. Despite supportive evidence of its effectiveness, this ancient approach is often misunderstood, and may still be underused in mainstream practice. A critical review on its effectiveness and practice integration, and mechanisms of action is essential to the medical community that is continuing to seek nonopioid therapies for chronic pain. Mounting evidence supports the effectiveness of acupuncture to treat chronic low back, neck, shoulder, and knee pain, as well as headaches. Additional data are emerging that support the use of acupuncture as an adjunct or alternative to opioids, and in perioperative settings. Findings related to its mechanisms of action include transient receptor potential cation channel vanilloid 1 activation in the periphery, microglial suppression in the cerebral cortex and spinal cord, and regulation of cytokines and other key inflammatory factors in the spinal cord. Incremental integration of acupuncture into pain medicine practices and training programmes continues to grow. Acupuncture is effective, safe, and cost-effective for treating several chronic pain conditions when performed by well-trained healthcare professionals. Further studies on its use as an adjunct or alternative to opioids, and in perioperative settings are needed.

Interview with David Tauben: University of Washington, Chief of the Division of Pain Medicine.

Dr Tauben is Clinical Professor jointly appointed in the Departments of Medicine and Anesthesia & Pain Medicine, and is the Hughes M & Katherine G Blake Endowed Professor, board certified in both Internal Medicine and Pain Medicine. He is also University of Washington (UW) Director of Medical Student and Resident Education in Pain Medicine, and Medical Director of UW TelePain, a tele-video-conferencing program intended to provide innovative pain education and consultative support to a five-state northwest regional primary care providers. He served as a member of the NIH National Pain Strategy task force on pain education and is principal investigator for the UW's prestigious NIH Pain Consortium Center of Excellence for Pain Education, leading curriculum development to extend the pain proficiency qualifications of interprofessional primary care providers. Dr Tauben is a member of the American Pain Society and the International Association for the Study of Pain special interest study groups on Pain Education. He is a founding member of the State of Washington Agency Medical Directors panel of medical experts developing opioid prescription guidelines for the state, and a regular clinical and content expert for regulatory and legislative bodies involved in public policy regarding pain medicine practice and standards. He speaks as a clinical expert in medical management of chronic pain, especially as it applies to primary care practices. Dr Tauben served as an expert for several US Centers for Disease Control clinical outreach programs and policy reviews advising primary care providers on how to prescribe opioids for chronic noncancer pain. He is annually recognized by his peers as recipient of regional awards in care of pain patients, and brings decades of clinical experience of best practice medication management of acute and chronic pain. Dr Tauben received his bachelors degree in philosophy from Yale University, medical degree from Tufts University School of Medicine and completed his residency training at the UW, in Seattle. He is a fellow of the American College of Physicians.

Exploring the Facets of Empathy and Pain in Clinical Practice: A Review.

Empathy is an essential element in providing quality patient care. The significance of empathy is even more striking in pain medicine, as chronic pain is notorious for the way it can compromise an individual, leaving him or her isolated and feeling misconceived. This review examines the role of empathy in pain medicine practice. Current and past literature focusing on empathy and pain was searched for in PubMed, Science Direct, MEDLINE (Ovid), MEDLINE (Ebsco), Research Gate, and Google Scholar in July 2015. Search dates were not limited and languages included English only. Search terms were "empathy and pain," "empathy and chronic pain," "physician empathy and pain," "neural mechanisms and empathy," "empathy in clinical practice," "empathy and stigma," and "empathy and medical students". To select relevant publications, the title and abstract of every publication were examined, and when in doubt, the rest of the publication was read. Four major themes were identified: (1) the neural basis for empathy and pain; (2) the value and challenges of practicing empathy pain medicine; (3) stigma and empathy for pain; and (4) empathy and physician education and training. The review reveals that empathy deserves an unchallenged place in medical care, especially in pain medicine and medical education. It highlights the need to nurture empathy at all levels of professional expertise from medical student to senior doctors.

Pain Medicineand Oxford University Press: Building a Scholarly Pain Community Together

Pain Medicine has grown rapidly over its first 16 years thanks to authors from around the world who have contributed their scholarly work for review and publication as well as to the dedication of its editorial board, editorial staff, reviewers, and publisher. This January 2016 issue of Pain Medicine is the first with our new publishing partner, Oxford University Press (OUP), with whom we have forged a very strong 5 year publishing agreement. Oxford, fully aware of the growth of our field and the important roles of our three sponsoring societies (American Academy of Pain Medicine [AAPM], the Spine Intervention Society [SIS], and the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists [FPM ANZCA]) in national and international pain medicine, believe, as we do, that Pain Medicine has a bright future. I am most grateful to leaders from these societies as well as from members of our own editorial board (particularly Drs. Bogduk, Harden, Lamer, Maus, and Webster), who assisted in this process. Oxford’s Pain Medicine team, led by Rachel Warren, has worked diligently with our managing editor, Colleen Healy, and editorial and AAPM staff to guarantee a smooth transition from Wiley. Managing publisher Alison Labbate, a strong partner in growing Pain Medicine at Blackwell and then Wiley after their merger, has helped smooth the transition, and we are most grateful for her, and her team’s, service over the years. Oxford joins our Pain Medicine enterprise at an important time in the history of pain medicine research, practice, and policy. The costs of the public health problem of pain and its consequence—opioid over-use—have made health services research increasingly important. We must now consider a population-based approach to managing costs and to improving safety and quality-of-life outcomes, with a focus on primary prevention (engaging people …

Hypertonic-Dextrose Intra-Articular Injections in Severe Knee Osteoarthritis: A Pilot Study Suggesting Disease Modification through Chondrogenesis

Objective(s): To assess biological and clinical effects of intra-articular hypertonic dextrose injections in painful severe knee osteoarthritis (KOA). Hypertonic dextrose injection is reported to improve KOA-related pain, stiffness and function, but its effect on articular cartilage is unknown. Design: Open label pilot study. Setting: Outpatient pain medicine and day surgery practice. Participants: Adults with knee pain for at least 6 months, arthroscopyconfirmed medial compartment Outerbridge IV KOA, and temporary pain relief with intra-articular lidocaine injection. Interventions: 6 monthly 10 mL intra-articular injections with 12.5% dextrose. Main Outcome Measure(s): Assessed at baseline and 7.5 2.0 (range 4.59.5) months: Video arthroscopy of 9 standardized medial condyle zones was performed before and after treatment; semi-quantitative visual cartilage growth assessment of each zone (+1.0,-1) was performed by 3 surgeon-reviewers. Biopsies of cartilage growth-area was obtained posttreatment and evaluated using HE Fleiss kappa Z0.901).Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibroand hyaline-like cartilage. Compared with baseline status, participants reported improved WOMAC scores (17.6 4.7 points; pZ.013). Self-limited soreness after methylene-blue instillation was noted. Conclusions: Positive clinical and chondrogenic effects were seen after hypertonic dextrose injection in symptomatic grade IV KOA suggesting disease-modifying effects and the need for confirmation in controlled studies.

Concurrent Dextrose Prolotherapy and Physical Therapy in Painful Rotator Cuff Tendinopathy: A Randomized Controlled Trial

Objective(s): To assess the efficacy of concurrent dextrose prolotherapy and physical therapy in reducing pain and reversing degenerative changes in participants with painful rotator cuff tendinopathy. Design: Randomized double-bind controlled trial. Setting: Outpatient pain medicine practice. Participants: Chronic shoulder pain and ultrasound-confirmed rotator cuff tendinopathy. Interventions: Delayed treatment control period, followed by concurrent physical therapy (six sessions) and three monthly solution-and-depthconcealed (participant, evaluator) or solution-concealed (injector) injections of normal saline/0.1% lidocaine either above (Superfic-Saline) or onto painful entheses (Enth-Saline), or onto entheses with 25% dextrose included (Enth-Dex). Main Outcome Measure(s): Primary: 0-10 Visual Analog Score (VAS) for pain, 0-10 Ultrasound Pathology Rating Scale (USPRS) and a 0-10 satisfaction score. Results: No baseline differences between groups in demographics or duration of delayed treatment control period (3.5 2.1months; pZ.920). The 74 participants had moderate to severe shoulder pain (7.0 2.0) for 7.6 9.6 years. Only 7 participants were both confident and correct about their group assignment with no difference between groups. Each group significantly outperformed their delayed treatment control at short term (3 month) followup. At 9 month follow-up 59 percent of Enth-Dex participants maintained a 2.8 improvement in VAS pain(twice the MCID) compared to Enth-Saline (35%;pZ.088) and Superfic-Saline (27%;pZ.017), and Enth-Dex participants’ satisfaction was 6.7 3.2 (10Z completely satisfied) compared to Enth-Saline (4.7 4.1;pZ.079) and Superfic-Saline (3.9 3.1;pZ.003) participants. USPRS findings were not different between groups (p Z .734). Conclusions: Concurrent physical therapy and dextrose prolotherapy resulted in superior long term pain improvement and satisfaction in chronically painful rotator cuff tendinopathy in comparison with physical therapy and a superficial saline control injection, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect.

Small Needle Vertical Caudal Epidural Injection Method: Success Rate and Safety Profile

Objective(s): To assess the efficacy of concurrent dextrose prolotherapy and physical therapy in reducing pain and reversing degenerative changes in participants with painful rotator cuff tendinopathy. Design: Randomized double-bind controlled trial. Setting: Outpatient pain medicine practice. Participants: Chronic shoulder pain and ultrasound-confirmed rotator cuff tendinopathy. Interventions: Delayed treatment control period, followed by concurrent physical therapy (six sessions) and three monthly solution-and-depthconcealed (participant, evaluator) or solution-concealed (injector) injections of normal saline/0.1% lidocaine either above (Superfic-Saline) or onto painful entheses (Enth-Saline), or onto entheses with 25% dextrose included (Enth-Dex). Main Outcome Measure(s): Primary: 0-10 Visual Analog Score (VAS) for pain, 0-10 Ultrasound Pathology Rating Scale (USPRS) and a 0-10 satisfaction score. Results: No baseline differences between groups in demographics or duration of delayed treatment control period (3.5 2.1months; pZ.920). The 74 participants had moderate to severe shoulder pain (7.0 2.0) for 7.6 9.6 years. Only 7 participants were both confident and correct about their group assignment with no difference between groups. Each group significantly outperformed their delayed treatment control at short term (3 month) followup. At 9 month follow-up 59 percent of Enth-Dex participants maintained a 2.8 improvement in VAS pain(twice the MCID) compared to Enth-Saline (35%;pZ.088) and Superfic-Saline (27%;pZ.017), and Enth-Dex participants’ satisfaction was 6.7 3.2 (10Z completely satisfied) compared to Enth-Saline (4.7 4.1;pZ.079) and Superfic-Saline (3.9 3.1;pZ.003) participants. USPRS findings were not different between groups (p Z .734). Conclusions: Concurrent physical therapy and dextrose prolotherapy resulted in superior long term pain improvement and satisfaction in chronically painful rotator cuff tendinopathy in comparison with physical therapy and a superficial saline control injection, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect.

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

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

Dextrose Prolotherapy Versus Control Injections in Painful Rotator Cuff Tendinopathy

ObjectiveTo compare the effect of dextrose prolotherapy on pain levels and degenerative changes in painful rotator cuff tendinopathy against 2 potentially active control injection procedures. DesignRandomized controlled trial, blinded to participants and evaluators. SettingOutpatient pain medicine practice. ParticipantsPersons (N=73) with chronic shoulder pain, examination findings of rotator cuff tendinopathy, and ultrasound-confirmed supraspinatus tendinosis/tear. InterventionsThree monthly injections either (1) onto painful entheses with dextrose (Enthesis-Dextrose), (2) onto entheses with saline (Enthesis-Saline), or (3) above entheses with saline (Superficial-Saline). All solutions included 0.1% lidocaine. All participants received concurrent programmed physical therapy. Main Outcome MeasuresPrimary: participants achieving an improvement in maximal current shoulder pain ≥2.8 (twice the minimal clinically important difference for visual analog scale pain) or not. Secondary: improvement in the Ultrasound Shoulder Pathology Rating Scale (USPRS) and a 0-to-10 satisfaction score (10, completely satisfied). ResultsThe 73 participants had moderate to severe shoulder pain (7.0±2.0) for 7.6±9.6 years. There were no baseline differences between groups. Blinding was effective. At 9-month follow-up, 59% of Enthesis-Dextrose participants maintained ≥2.8 improvement in pain compared with Enthesis-Saline (37%; P=.088) and Superficial-Saline (27%; P=.017). Enthesis-Dextrose participants' satisfaction was 6.7±3.2 compared with Enthesis-Saline (4.7±4.1; P=.079) and Superficial-Saline (3.9±3.1; P=.003). USPRS findings were not different between groups (P=.734). ConclusionsIn participants with painful rotator cuff tendinopathy who receive physical therapy, injection of hypertonic dextrose on painful entheses resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline. These differences could not be attributed to a regenerative effect. Dextrose prolotherapy may improve on the standard care of painful rotator cuff tendinopathy for certain patients.

Simulation in teaching regional anesthesia: current perspectives.

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

Patient-reported outcomes in a large community-based pain medicine practice: evaluation for use in phenotype modeling.

BackgroundAn academic, community medicine partnership was established to build a phenotype-to-outcome model targeting chronic pain. This model will be used to drive clinical decision support for pain medicine in the community setting. The first step in this effort is an examination of the electronic health records (EHR) from clinics that treat chronic pain. The biopsychosocial components provided by both patients and care providers must be of sufficient scope to populate the spectrum of patient types, treatment modalities, and possible outcomes.MethodsThe patient health records from a large Midwest pain medicine practice (Michigan Pain Consultants, PC) contains physician notes, administrative codes, and patient-reported outcomes (PRO) on over 30,000 patients during the study period spanning 2010 to mid-2014. The PRO consists of a regularly administered Pain Health Assessment (PHA), a biopsychosocial, demographic, and symptomology questionnaire containing 163 items, which is completed approximately every six months with a compliance rate of over 95 %. The biopsychosocial items (74 items with Likert scales of 0–10) were examined by exploratory factor analysis and descriptive statistics to determine the number of independent constructs available for phenotypes and outcomes. Pain outcomes were examined both in the aggregate and the mean of longitudinal changes in each patient.ResultsExploratory factor analysis of the intake PHA revealed 15 orthogonal factors representing pain levels; physical, social, and emotional functions; the effects of pain on these functions; vitality and health; and measures of outcomes and satisfaction. Seven items were independent of the factors, offering unique information. As an exemplar of outcomes from the follow-up PHAs, patients reported approximately 60 % relief in their pain. When examined in the aggregate, patients showed both a decrease in pain levels and an increase in coping skills with an increased number of visits. When examined individually, 80-85 % of patients presenting with the highest pain levels reported improvement by approximately two points on an 11-point pain scale.ConclusionsWe conclude that the data available in a community practice can be a rich source of biopsychosocial information relevant to the phenotypes of chronic pain. It is anticipated that phenotype linkages to best treatments and outcomes can be constructed from this set of records.

Interventional orthopedics in pain medicine practice

Interventional pain physicians are in a unique place to take advantage of regenerative medicine technology to improve patient outcomes and decrease the invasiveness of orthopedic procedural care. However, that sea of change would take significant changes to the educational system similar to those established when interventional spine was first introduced as a subspecialty. The tenets of interventional orthopedics are as follows: injectates that can facilitate healing of musculoskeletal tissues, precise placement of those injectates into damaged structures using imaging guidance, and the eventual development of new tools to facilitate percutaneous tissue manipulation. Stem cells are an early injectate being used in this developing field. The research supporting the use of stem cells to treat orthopedic conditions is more robust than many realize. Early clinical work to treat osteonecrosis and fracture nonunion began in the 1990s. Today, early clinical evidence to support the use of bone marrow concentrate to treat knee osteoarthritis and other orthopedic conditions exists and continues to develop. Although more research needs to be completed, the increased availability of biologic agents that can prompt healing in musculoskeletal tissues would usher in a new field of medicine—interventional orthopedics.

Obesity and chronic pain: systematic review of prevalence and implications for pain practice.

The combination of obesity and pain may worsen a patient's functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.

The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015.

The Second American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine updates information that was originally presented at the Society's first open forum on this subject (2005) and published in 2008. Portions of the second advisory were presented in an open forum (2012) and are herein updated, with attention to those topics subject to evolving knowledge since the first and second advisory conferences. The second advisory briefly summarizes recommendations that have not changed substantially. New to this iteration of the advisory is information related to the risk of nerve injury inherent to common orthopedic surgical procedures. Recommendations are expanded regarding the preventive role of various monitoring technologies such as ultrasound guidance and injection pressure monitoring. New clinical recommendations focus on emerging concerns including spinal stenosis and vertebral canal pathologies, blood pressure management during neuraxial anesthesia, administering blocks in anesthetized or deeply sedated patients, patients with preexisting neurologic disease, and inflammatory neuropathies. An updated diagnostic and treatment algorithm is presented.

Nicotine smoking: Influences on perioperative pain management

BackgroundThe complex relationship between smoking and pain has clinical relevance in the practice of anesthesiology and pain medicine. The present study investigated the effect of heavy nicotine smoking on perioperative pain management.MethodsThis prospective controlled study was carried out in Alexandria Main University hospital on 80 adult ASA I and II patients scheduled for lower limb fractures fixation under general anesthesia after an informed written consent and approval of the Medical Ethics Committee. Patients were divided into 2 groups: group N included nonsmokers and group S included the heavy smokers. Intraoperative heart rate (HR), mean arterial blood pressure (MAP) and intraoperative analgesia were recorded. Postoperatively; HR, MAP, pain visual analog scale (VAS) and total postoperative analgesic requirements were recorded.ResultsIntraoperative and postoperative HR and MAP showed significantly higher values in group S patients than group N patients. VAS values were significantly lower in group N than group S at recovery, 8 and 24 h postoperatively. Total intraoperative and postoperative analgesic requirements of meperidine were significantly lower in group N than group S.ConclusionsChronic nicotine smoking increases the incidence of perioperative pain. Heavy smokers need more perioperative analgesia than nonsmokers.

Efficacy vs Effectiveness and Explanatory vs Pragmatic: Where Is the Balance Point in Pain Medicine Research?

In this issue of Pain Medicine , there is a study by Cohen and colleagues that investigates the effect of procedural sedation on diagnostic and therapeutic outcomes for sacroiliac joint and sympathetic nerve block procedures [1]. They found that procedural sedation is associated with an increased rate of false positive blocks and had no significant effects on patient satisfaction or clinical outcomes at 1 month. Although this is a crucial issue relevant to the day-to-day practice of pain medicine, this elegantly designed study also broaches in a sophisticated manner the divide between explanatory and pragmatic trials. Their study design results in findings that are of high scientific quality and yet broadly applicable to routine interventional pain medicine care. Randomized trials can be broadly characterized as an effectiveness or efficacy trial, and the corresponding terms “pragmatic” vs “explanatory” are often used [2]. Pragmatic trials …