Received Muscle Relaxants Research Articles

681 Postoperative Muscle Relaxant Use Associated With Increased Risk of Delirium Following Lumbar Spinal Fusion

INTRODUCTION: Muscle relaxants including cyclobenzaprine and baclofen are frequently utilized in pain management following spine surgery as part of enhanced recovery after surgery (ERAS) protocols. These medications are associated with anticholinergic and central nervous system side effects and are used with caution in outpatient treatment for those at high-risk of delirium, especially the elderly. Literature investigating their association with delirium in the postoperative setting has not been described. METHODS: Patients over age 65 undergoing elective posterior lumbar fusion between 2017 and 2021 at the senior author’s institution were retrospectively reviewed. Variables collected included patient demographics as well as whether subjects received postoperative administration of baclofen and/or cyclobenzaprine on postoperative day 1 as part of a multimodal analgesia regimen. Doubly-robust inverse probability weighting (IPW) with cox-regression was used to evaluate the incidence of postoperative delirium between groups. RESULTS: Five-hundred and thirty-one patients were included in the analysis. Incidence of delirium in those who received postoperative muscle relaxants was 17.6% (44/250) compared to 11.4% (32/281) in the control group who did not (p = 0.001). Doubly-robust IPW analysis found patients who received muscle relaxants were at a 2.07 (95% CI: 1.18-3.63) times increased risk of delirium compared to controls (p = 0.015). Postoperative time to delirium onset was similar between groups (3.0 vs 3.1 days; p = 0.916) while the average duration of delirium was significantly longer in those who received postoperative muscle relaxants (2.5 vs 1.6 days; p = 0.008). CONCLUSIONS: Postoperative muscle relaxant use was associated with a higher risk of delirium in elderly adults following lumbar spinal fusion. Although muscle relaxants may assist with postoperative pain control as part of ERAS protocols while minimizing opioid administration, their side effect profile should be considered in patients at high risk of postoperative delirium.

Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion.

Retrospective, single-center, cohort study. Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration. Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting. Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics. The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ). Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.

Stress reduction interventions for patients with chronic diabetic foot ulcers: a qualitative study into patients and caregivers’ perceptions

BackgroundThe present study aimed to assess the perceptions of patients with chronic diabetic foot ulcers (DFUs) and their family caregivers regarding the impact of two stress reduction interventions on DFU and psychological wellbeing. The intervention included progressive muscle relaxation and hypnosis sessions.MethodsThis study used a qualitative exploratory design and included individual interviews with eight patients with chronic DFUs and six family caregivers, using a semi-structured interview guide. Transcript analysis employed thematic content analysis.ResultsFour key themes common to patients and their caregivers were found: 1) perspectives regarding the intervention; 2) intervention effectiveness; 3) perceived importance of psychology in the DFU treatment; and 4) emotional consequences associated with DFUs. Although themes were common to both intervention groups, sub-themes from the last two themes differed for patients that received muscle relaxation versus those who received hypnosis.ConclusionPatients and caregivers reported perceived benefits from both interventions, regarding DFU healing and emotional wellbeing. Patients who received hypnosis and their caregivers also reported lasting effects. Participants suggested that psychological interventions such as stress reduction interventions could be included in the DFU standard treatment as an adjuvant to the clinical protocol for DFU treatment, preferably offered early on, when patients begin treatment at the diabetic foot consultation.

Применение комплексных лекарственных препаратов для лечения пациентов с болью в спине

Purpose of the study: to assess the dynamics of pain indicators and various characteristics of the quality of life in patients with back pain when using a one-course treatment complex with the use of Clodifen Neuro. Materials and methods. The study included men and women aged 44 to 52 years with complaints of lower back pain caused by exacerbation of chronic dorsalgia. The main group included 30 patients (14 men and 16 women). The control group consisted of 24 patients (12 men and 12 women). The groups were comparable in terms of the severity of symptoms and the length of the disease. All patients received muscle relaxants and gastroprotectors of the corresponding pharmacological groups, patients in the main group received Clodifen Neuro 1 capsule twice a day for 2 weeks, patients in the control group received diclofenac tablets (enteric form) 50 mg twice a day. The effectiveness of therapy was assessed using the VAS scale and the Oswestry questionnaire. Assessment of the condition of patients in both groups was carried out before the start of the study, after the end of treatment (after 14 days) and 2 months after the end of therapy. Results. The study of the effectiveness of the use of Clodifen Neuro showed that in patients with chronic back pain, the drug favored a decrease in pain syndrome, an increase in the mobility of the spine, and the functional potential of patients. Conclusion. Treatment with Clodifen Neuro for 14 days (1 capsule orally 2 times a day) as a part of complex therapy contributed to a steady reduction in pain in the study group of patients with chronic back pain. The analgesic effect persisted for 2 months after the end of therapy. Clodifen Neuro can be recommended as a polytropic agent in the complex therapy of chronic back pain.

Effect of muscle relaxants on the prognosis of neonates with congenital esophageal atresia-tracheoesophageal fistula after surgery

OBJECTIVE To summarize the experience in the application of muscle relaxants in the perioperative period in neonates with congenital esophageal atresia-tracheoesophageal fistula (EA-TEF). METHODS A retrospective analysis was performed on the medical data of 58 previously untreated neonates with EA-TEF who were treated in the Neonatal Center of Beijing Children's Hospital, Capital Medical University from 2017 to 2019. The incidence rate of anastomotic leak was compared between the neonates receiving muscle relaxants for different durations after surgery (≤ 5 days and > 5 days). The correlation between the duration of postoperative use of muscle relaxants and the duration of mechanical ventilation was evaluated. RESULTS Among the 58 neonates with EA-TEF, 44 underwent surgery, among whom 35 with type III EA-TEF underwent thoracoscopic surgery. Among these 35 neonates, 30 (86%) received muscle relaxants after surgery, with a median duration of 4.75 days, and 6 (18%) experienced anastomotic leak. There was no significant difference in the incidence rate of anastomosis leak between the ≤ 5 days and > 5 days groups (P > 0.05). The duration of postoperative invasive mechanical ventilation was positively correlated with the duration of the use of muscle relaxants (rs=0.548, P < 0.05). CONCLUSIONS Prolonged use of muscle relaxants after surgery cannot significantly reduce the incidence of anastomotic leak, but can prolong the duration of invasive mechanical ventilation in neonates with EA-TEF. Therefore, prolonged use of muscle relaxants is not recommended after surgery.

Muscle relaxant use and the associated risk of incident frailty in patients with diabetic kidney disease: a longitudinal cohort study.

Background:Patients with diabetic kidney disease (DKD) are at an increased risk of frailty. The exposure to muscle relaxants frequently leads to adverse effects despite their modest therapeutic efficacy, but whether muscle relaxants predispose users to frailty remains unclear.Methods:Patients with DKD from a population-based cohort, the Longitudinal Cohort of Diabetes Patients, were identified between 2004 and 2011 (N = 840,000). Muscle relaxant users were propensity score-matched to never-users in a 1:1 ratio based on demographic features, comorbidities, outcome-relevant medications, and prior major interventions. Incident frailty, the study endpoint, was measured according to a modified FRAIL scale. We used Kaplan–Meier analyses and Cox proportional hazard regression to analyze the association between cumulative muscle relaxant use (⩾ 28 days) and the risk of incident frailty.Results:Totally, 11,637 users and matched never-users were enrolled, without significant differences regarding baseline clinical features. Cox proportional hazard regression showed that patients with DKD and received muscle relaxants had a significantly higher risk of incident frailty than never-users [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.04–1.53]. This increase in frailty risk paralleled that in cumulative muscle relaxant dosages (quartile 1 versus 2 versus 3 versus 4, HR 0.91 versus 1.22 versus 1.38 versus 1.45, p = 0.0013 for trend) and in exposure durations (quartile 1 versus 2 versus 3 versus 4, HR 1.12 versus 1.33 versus 1.23 versus 1.34, p = 0.0145 for trend) of muscle relaxants.Conclusion:We found that cumulative muscle relaxant exposure might increase frailty risk. It is prudent to limit muscle relaxant prescription in patients with DKD.Plain language summary Does cumulative muscle relaxant exposure increase the risk of incident frailty among patients with diabetic kidney disease? Background: Frailty denotes a degenerative feature that adversely influences one’s survival and daily function. Patients with diabetes and chronic kidney disease are at a higher risk of developing frailty, but whether concurrent medications, especially muscle relaxants, aggravate this risk remains undefined.Methods: In this population-based study including 11,637 muscle relaxant users and matched never-users with diabetic kidney disease, we used a renowned frailty-assessing tool, FRAIL scale, to assess frailty severity and examined the incidence of frailty brought by muscle relaxant exposure.Results: We found that users exhibited a 26% higher risk of developing incident frailty compared with never-users, and the probability increased further if users were prescribed higher doses or longer durations of muscle relaxants.Conclusion: We concluded that in those with diabetic kidney disease, cumulative muscle relaxant use was associated with a higher risk of incident frailty, suggesting that moderation of muscle relaxant use in this population can be of potential importance.

Use of a Servo-Controlled Cooling Gel Pad System to Regulate Body Temperature in Critically Ill Children.

To assess the efficacy and safety of a servo-controlled cooling pad system for target temperature management in critically ill pediatric patients. A prospective, single-center, observational study. PICU of a tertiary hospital from September 2018 to September 2019. Children from 28 days to 16 years old subjected to servo-controlled body temperature control. The Arctic Sun 5000 system (Bard Medical, Covington, GA) and Arctic Gel Hydrogel pads were used for the purposes of the study. Data collected included demographics, indication of therapy, patient's body temperature, target temperature, time-to-target temperature, duration of therapy, and need to start or increase sedation and/or muscle relaxants. A total of 16 patients were included, of whom 68.8% were male; mean age was 4.7 years. The most frequent indication was fever associated with hemodynamic instability (62.5%). The target temperature was normothermia (36 or 36.5°C) in 81% of cases. Mean baseline body temperature was 37.6°C (± 1.2°C), and 50% of patients had fever (> 38°C). The mean speed of cooling was 1.2°C/hr (± 1°C/hr). Mean time to target temperature was 118 minutes (± 98.8 min). Mean duration of therapy was 68.7 hours (± 58.3 hr). Two patients had fever related to device disconnection during the treatment. At the start of the therapy, 15 patients were receiving sedative and analgesic drugs, and four received muscle relaxants. A patient required increased sedation, whereas another patient needed to start muscle relaxants. One of the patients developed a skin lesion in the axilla, no other adverse events were registered. Despite the small sample size, the results of the study showed that target temperature management by the servo-controlled gel pad system in critically ill pediatric patients was effective in achieving satisfactory temperature control and it was well-tolerated.

Safe And Feasible Exercises For The Paravertebral Muscles In Cancer Patients With Unstable Spinal Metastases

PURPOSE: Previous work showed that cancer patients with spinal metastases classified as stable (i.e. with low fracture risk) benefit from isometric exercises for the paravertebral muscles concomitant to palliative radiotherapy in terms of bone density and pain. In this exploratory randomized controlled trial we investigated whether paravertebral muscle training is safe and feasible also in patients with spinal metastases classified as unstable (i.e. with high fracture risk). METHODS: Sixty cancer patients with unstable spinal metastases (Taneichi score ≥D) were randomized to an intervention group (INT, n=27 starters) or a control group (CON, n=29 starters). INT received 15 min of 1:1-supervised isometric exercises (“all fours”, “plank”, “swimmer”, and a standing exercise with an elastic band) daily on 10±2 days of radiotherapy and continued home-based on 3 days/week for 3 months. CON received muscle relaxation. Adverse events and adherence (primary endpoints), strength, pain and quality of life (secondary endpoints) were assessed. RESULTS: In 41% of patients, exercises were modified because of pain or immobility. There were no training-related adverse events. During radiotherapy, 67% of patients in INT and 55% of patients in CON attended ≥80% of the planned training sessions. During home-based training, 64% of patients in INT performed ≥80% of the planned training sessions. Plank position holding time (strength) increased by 24±28 s in INT and dropped by 2±34 s in CON by the end of radiotherapy (p=0.01). There were no differences between groups for pain or quality of life (p>0.05). CONCLUSIONS: The described or individually modified isometric exercises for the paravertebral muscles are safe and in about 2/3 of cancer patients with unstable spinal metastases feasible when introduced 1:1 and continued home-based. To investigate potential benefits, larger studies powered for patient reported outcomes and clinical endpoints are needed.

MHealth: providing a mindfulness app for women with chronic pelvic pain in gynaecology outpatient clinics: qualitative data analysis of user experience and lessons learnt

ObjectivesTo determine whether a pre-existing smartphone app to teach mindfulness meditation is acceptable to women with chronic pelvic pain (CPP) and can be integrated into clinical practice within the National...

Pain and nausea after bariatric surgery with total intravenous anesthesia versus desflurane anesthesia: a double blind, randomized, controlled trial

BackgroundThere is limited evidence-based knowledge regarding optimal anesthesia in obese patients. ObjectiveTo evaluate optimal anesthetic approach for patients undergoing bariatric surgery by determining and comparing peri- and postoperative outcomes in patients receiving intravenous anesthesia with propofol versus desflurane anesthesia. SettingNonacademic primary referral center. MethodsPatients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass between 2016 and 2017 were randomized into 1 of the following 2 types of anesthesia: intravenous anesthesia with propofol, or desflurane. Perioperative outcomes were registered by the operation staff. A form based on visual analog scale estimating the patient’s intensity of pain and nausea was completed postoperatively at the postoperative unit, surgical ward, and 24 to 48 hours postsurgery. The primary outcome was postoperative nausea and vomiting or postoperative pain between treatment groups. The secondary outcome was to evaluate the “time of awakening,” peritoneal stretch, and use of perioperative muscle relaxants. ResultsOne hundred eighty-three patients were randomized to receive intravenous anesthesia (n = 90) or desflurane anesthesia (n = 93). Mean time ± standard deviation of surgery for both procedures was 41 ± 17 minutes, whereas mean time of awakening was 2 ± 2 minutes for both the intravenous anesthesia and desflurane group. There was no significant difference in visual analog scale for pain or for nausea and vomiting postoperatively, nor in the number of patients receiving muscle relaxants for peritoneal stretch between the 2 groups. ConclusionsWe found no significant differences between the 2 anesthetic regimens regarding postoperative nausea and pain, awakening time, peritoneal stretch, or the use of perioperative muscle relaxants.

Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes

Muscle relaxants are often used to treat musculoskeletal pain or cramping, which are commonly experienced by hemodialysis patients. However, the extent to which muscle relaxants are prescribed in this population and the risks associated with their use have not been characterized. Observational cohort study. 140,899 Medicare-covered adults receiving hemodialysis in 2011, identified in the US Renal Data System. Time-varying muscle relaxant exposure. Primary outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, or fracture. Secondary outcomes were death and composites of death with each of the primary outcomes. Multivariable Cox regression analysis. 10% of patients received muscle relaxants in 2011. 11%, 6%, 3%, and 13% had an episode of altered mental status, fall, fracture, and death, respectively. Muscle relaxant use was associated with higher risk for altered mental status (HR, 1.39; 95% CI, 1.29-1.51) and fall (HR, 1.18; 95% CI, 1.05-1.33) compared to no use. Muscle relaxant use was not statistically significantly associated with higher risk for fracture (HR, 1.17; 95% CI, 0.98-1.39). Muscle relaxant use was associated with lower hazard of death (HR, 0.85; 95% CI, 0.76-0.94). However, hazards were higher for altered mental status or death (HR, 1.17; 95% CI, 1.10-1.25), fall or death (HR, 1.14; 95% CI, 1.06-1.22), and fracture or death (HR, 1.10; 95% CI, 1.01-1.20). A causal association between muscle relaxant use and outcomes cannot be inferred, and residual confounding cannot be excluded. Exposure and outcomes were ascertained using administrative claims. Muscle relaxant use was common in hemodialysis patients and associated with altered mental status and falls. We could not rule out a clinically meaningful association between muscle relaxant use and fracture. The lower risk for death with muscle relaxants may have been the result of residual confounding. Future research to define the appropriate use of muscle relaxants in this population is warranted.

Age-related changes in physiology of blood circulation, breath and appropriate anaesthetic considerations in patients older than 60 years. Review

The presence of co-existing diseases and age-related physiological changes in blood circulation and breath are the main reasons for the increase in postoperative complications and 30 days mortality in patients over 60 years of age. A gradual increase in arterial blood pressure (ABP) usually begins in people older than 50 years. According to recommendations of the most anaesthesiologist societies, ABP above 180/110 mm Hg is the reason for canceling a scheduled surgical operation. However, no convincing evidences have yet been presented that high preoperative ABP as an isolated factor without some organ failures can lead to an increase in the amount of postoperative complications and early mortality. Meanwhile, low ABP both before surgery and/or during anaesthesia is a reliable proven factor in increasing the amount of postoperative complications and 30 days mortality. Surgery, which in itself carries out a high risk of the rapid development of arterial hypotension, such as for example vascular interventions with a high risk of bleeding, requires the use of an invasive measurement of ABP, which covers those temporary time pauses between measurements of non-invasive ABP. A clear advantage of one anaesthetic technique over another in reducing peri-operative arterial hypotension (PAH) and postoperative pulmonary complications in patients over 60 years of age has not been demonstrated. Based on pathogenesis of PAH for normovolemic patients, it makes no sense to correct PAH caused by vasodilation of arterioles and venules, by intravenous fluid administration, when there is a need to compensate for the missing norepinephrine. In patients at high risk of developing PAH, it is necessary to start the infusion of norepinephrine directly during induction of anaesthesia. In patients who received muscle relaxants during anaesthesia, the risk of developing postoperative pneumonia increases by 1.79 times, and in patients who received muscle relaxants without reversal with an acetylcholinesterase inhibitors the risk of developing postoperative pneumonia increases by 2.26 times. Early mobilization of elderly patients after surgery can help to prevent almost all postoperative complications.

Effects of a cardiorespiratory synchronization training mobile application on heart rate variability and electroencephalography in healthy adults.

Cardiorespiratory synchronization training (CRST) uses diaphragmatic breathing to increase balance in the autonomic nervous system and reduce negative emotions. CRST integrated with high-technology mobile applications affords innovative and convenient home-based training. This study examined the effects of a CRST mobile application on heart rate variability (HRV) and electroencephalography (EEG) parameters in healthy adults. Ninety-six participants were randomly assigned to the CRST, relaxation training (RT; active control group), and control (C) groups. The CRST group received paced breathing training using a wearable device connected to a mobile application and received feedback on the HRV indices. The RT group received muscle relaxation training using a wearable device connected to a mobile application and received feedback on heart rate (HR). The training program was conducted for 1 h per week for 4 weeks. The C group did not receive any wearable device, mobile application, or psychological intervention. Psychological questionnaires on depression and anxiety and physiological measurements of the breathing rates, electrocardiography (ECG), and EEG were measured at the pretest and posttest. The CRST group showed significantly higher HRV indices and lower breathing rates at the posttest than the RT and C groups. There were no significant interaction effects on EEG parameters at pretest and posttest among the three groups. Use of a CRST mobile application increased balance in the autonomic nervous system at the resting state. This clinical evidence-based technologically advanced mobile application could be implemented in future clinical practice.

An Exploratory Study of Sevoflurane as an Alternative for Difficult Sedation in Critically Ill Children.

To analyze the effectiveness of inhaled sevoflurane in critically ill children with challenging sedation. Prospective case series. Two PICUs of university hospitals in Spain. Prospective observational study and exploratory investigation conducted in two PICUs in Madrid, Spain, over a 6-year period. Children treated with inhaled sevoflurane due to difficult sedation were included. Sevoflurane was administered via the anesthetic conserving device (AnaConDa) connected to a Servo-I ventilator (Maquet, Solna, Sweden). A morphine infusion was added to sevoflurane for analgesia. Demographic and clinical data, oral and IV sedatives, Sedation and Analgesic Clinical scores, and Bispectral Index Score monitoring were registered. Twenty-three patients with a median age of 6 months old were included. Fifty percentage of the patients had critical heart diseases. Sedative and analgesic drugs used before starting sevoflurane were mainly midazolam (63%) and fentanyl (53%). Six patients (32%) also received muscle relaxants. Sevoflurane was administered for a median of 5 days (interquartile range, 5.5-8.5 d). Median end-tidal sevoflurane concentration was 0.8% (interquartile range, 0.7-0.85%), achieved with an infusion rate of 7.5 mL/hr (5.7-8.6 mL/hr). After 48 hours of treatment, some sedative drugs could be removed in 18 patients (78%). Median Bispectral Index Score value prior to sevoflurane administration was 61 (interquartile range, 49-62), falling to 42 (interquartile range, 41-47; p < 0.05) after 6 hours of treatment. Six patients (26%) presented withdrawal syndrome after sevoflurane suspension, and all of them had received sevoflurane at least for 6 days. The main side effect was moderate hypotension in seven patients (30%). Inhaled sevoflurane appeared to be an effective sedative agent in critically ill children and can be useful in those patients on mechanical ventilation difficult to sedate with conventional drugs. It can be administered easily in the PICU with conventional ventilators using the AnaConDa system. Withdrawal syndrome may occur with prolonged treatment.

Factors affecting the results of analgesic therapy. Results of the Russian multicentre study of NOTE (NSAID: Open-label Trial of Efficacy).

To identify factors affecting the effectiveness of NSAIDs in patients with OA and LBP. An observational study was conducted to evaluate the effectiveness of a 2-week course of NSAIDs in OA and LBP in real clinical practice. The study group consisted of 3604 patients with OA and LBP (60.6% women and 39.4% men, mean age 55.0±13.4 years). According to the study design, aceclofenac (Airtal) and other NSAIDs used in the ratio 1:1. The main criterion of effectiveness was the frequency of complete pain relief after 2 weeks of therapy. In addition, the decrease of pain and general health were determined on a 10-point numerical rating scale (NRS). We compared the frequency of complete pain relief in patients who had and did not have the studied factors. The value of the studied factors was determined using OR (95% CI). Most patients received aceclofenac (54.9%), as well as diclofenac (2.0%), ketoprofen (1.9%), lornoxicam (2.2%), meloxicam (13.7%), naproxen (2.1%), nimesulide (5.8%), celecoxib (5.9%), ethicoxib (7.1%) and other NSAIDs (4.4%); 56.2% of patients received muscle relaxants, mainly tolperisone (74.7%), vitamin B (10.4%), and proton pump inhibitors (42.8%). Complete pain relief was achieved in 54.8% of patients. The pain decrease and general health improvement were (for NRS) 63.9±13.4% and 61.7±14.8%, respectively. The efficacy of aceclofenac was slightly higher than in the whole group: complete pain relief was in 59.9% of patients. Adverse events in aceclofenac use were observed in 2.3% of patients, other NSAIDs-from 2.4 to 14.1%. The frequency of complete pain relief was higher in men: OR 1,239 (95% CI 1.08-1.418; p=0.002), who had the first episode of pain - OR 3.341 (95% CI 2.873-3.875; p=0.000), a good&quot; response &quot; to NSAIDs in history - OR 1.656 (95% CI 1.385-1.980; p=0.000) and received NSAIDs in combination with muscle relaxants - OR 1.218 (95% CI 1.067-1.390; p=0.004). The effect of therapy is lower in patients 65 years and older-OR 0,378 (95% CI 0.324-0.442; p=0,000), with body mass index &gt;30 kg/m² - OR 0.619 (95% CI 0.529-0.723; p=0.000), with severe pain (≥7 points NRS) - OR 0.662 (95% CI 0.580-0.756; p=0.002), with pain at rest, - OR 0.515 (95% CI 0.450-0,589; p=0.000), pain at night - OR 0.581 (95% CI 0.501-0.672; p=0.000) and the presence of stiffness - OR 0.501 (95% CI 0.438-0,573; p=0.000). Treatment results are significantly worse in the cases of combination of LBP and joint pain, as well as pain in the trochanter major and pes anserinus area (p&lt;0.001). NSAIDs are the first-line medications for the pain treatment in LBP and OA. Aceclofenac is effective and safe in this conditions. When carrying out analgesic therapy should take into account factors that affect the effectiveness of treatment: old age, overweight, insufficient effect of NSAIDs in history, severe pain, signs of &quot;inflammatory&quot; pain, multiple sources of pain.

Patterns of pain medication use in older individuals with cardiovascular disease

Background: Pain is common in older adults and clinicians are often faced by many challenges when selecting appropriate treatment due to age-related changes in pharmacokinetics, pharmacodynamics, increased comorbidities, and polypharmacy.Methods: This study assessed the patterns of pain medications used at home among older adults admitted to the cardiology service in a tertiary care teaching center in the US from March to May 2016. A retrospective chart review was conducted where adults, 65 years of age or older, with cardiovascular diseases admitted to the cardiology service and taking at least one pain medication at home were studied.Results: Out of 404 patients who were admitted to the cardiology service, 228 (56.4%) were on at least one pain medication. Among the admitted patients, 64.2% of the females received at least one pain medication, as compared to 49% of the males (p = 0.002). Participants had a mean age of 76.34 ± 7.43 years, and received a mean of 1.81 ± 0.83 pain medications. Neuropathic pain was the most common indication (33.4%), followed by arthritis (17.5%), and cancer (15.8%). The most commonly used pain medications were gabapentin/pregabalin 79 (34.6%), acetaminophen plus an opiate 78 (34.2%), opiates 56 (24.6%), tramadol 36 (15.8%), followed by non-selective NSAIDs 21 (9.2%). Twelve (5.3%) patients received duplication of pain medications, while 14 (5.7%) received an inappropriate combination of pain medications. Twenty-three patients (10.1%) received muscle relaxants in conjunction with pain medications, 20 of which are considered poorly tolerated by older adults.Conclusion: This stufy described the patterns of use of pain medications among older adults with cardiovascular disease. Careful selection of appropriate pain medications based on different clinical parameters is very essential to avoid prescribing inappropriate therapy that can lead to patient harm.

A comparative study between the bispectral index and the clinical score in the evaluation of sedation level in critically ill, mechanically ventilated patients

Background The 2013 sedation guidelines from the Society of Critical Care Medicine recommend using sedation scales to optimize sedation therapy. However, scales such as the Richmond Agitation–Sedation Scale (RASS) require subjective evaluation that may lead to variability in measurement and consequent clinical actions. The bispectral index (BIS) is an objective measure of the level of consciousness that is often used as anesthetic tool, and its use has broadened to include the ICU. Published data are still insufficient to warrant routine use of the BIS in critically ill patients. Aim The aim of this study was to compare the RASS with the BIS in measuring the level of sedation. Patients and methods This was a prospective study performed on 60 critically ill, adult, mechanically ventilated patients receiving sedation infusion. The BIS monitor was attached continuously to all patients for 3 days, and the digital readings were recorded every 4 h. The RASS was assessed and recorded at the same time. Statistical analyses were performed to assess the correlation between the two used modalities over time. Patients receiving muscle relaxants were excluded from the study. In addition, patients with head injuries or patients known to have any focal brain disease or abnormal electrical brain activities such as epilepsy were excluded. Results A total of 1080 readings comparing the RASS with the BIS were obtained from the 60 patients included in the present study over 3 days. No serious side-effects due to the BIS electrodes placed for 3 days were recorded. The correlation between RASS scores and BIS values was positive and statistically significant. The overall correlation scores in the 3 days were as follows − r=0.652, P less than 0.001 on day 1; r=0.685, P less than 0.001 on day 2; and r=0.686, P less than 0.001 on day 3. The correlation was statistically significant with the use of midazolam but not with dexmedetomidine. Conclusion An overall statistically significant, positive correlation between the BIS and the RASS was present. The BIS can be used as an adjunct for scoring.

Anxiety's Impact on Length of Stay Following Lumbar Spinal Surgery.

Despite some evidence that anxiety may affect length of stay (LOS), relatively little inquiry exists regarding this in neurosurgical literature. To determine the influence of anxiety on LOS after elective lumbar decompression and fusion (LDF) surgery. The medical records of 307 patients who consecutively underwent elective LDF surgery from October 1, 2010, through September 30, 2013, were retrospectively reviewed. Each patient's medications and comorbidities were determined using the medical history. The impact of their medications on LOS was studied using multivariate analysis. Linear regression was also used to assess the relationship between anxiolytic use and LOS. An independent sample t test was used to compare the mean LOS of the group of patients receiving muscle relaxants with that of the group who were not. Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.8 days longer than those with no diagnosis of anxiety and who were not taking anxiolytics (n = 224) after LDF surgery (p = 0.003). Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.9 days longer than those with no diagnosis of anxiety and who were taking anxiolytics (n = 24) after LDF surgery (p = 0.003). Our study suggests that those with a diagnosis of anxiety who take medications for that condition have a longer LOS than those with no diagnosis of anxiety and who are not medicated for the condition. This could be because these patients are more vulnerable to states of anxiety when required to be nil per os for 12 hours before surgery.

Variación de la masa muscular y el peso en el paciente crítico

ObjectivesQuantify the muscle mass and body weight variation in critically ill patients and to identify associated factors. MethodA descriptive follow-up study. Data for demographic variables, body weight, fluid balance, daily kilocalories, the amount of sedation and muscle relaxants received and motor physiotherapy applied were collected.Three consecutive measurements were performed in the brachial biceps and quadriceps rectus by using ultrasound, upon admission and every 5 days until discharge. Results68 patients were included. Average age was of 73.5 [57-78,5] years. The median length of stay was 9.5 [5.5 -15] days. The median 16 (SD=5.7) daily kilocalories per kg/weight, 91.2% received sedation, 44.1% received muscle relaxants and 20% received physiotherapy.The patients presented a muscle wasting of 4.9 (SD=3.9)mm, p <.001 in the brachial biceps and 5.6 (SD=4.8)mm, p <.001 in the quadriceps rectus. Regression analysis selected the length of stay and the muscle relaxants are the most influential variables in the brachial biceps muscle wasting (R2=0.4), and length of stay as the most influential in the quadriceps rectus muscle wasting (R2=0.3). Patient's mean body weight on admission was of 81.1 (SD=15)kg and 81.2 (SD=14.2)kg on discharge, p=.95. ConclusionsThe critically ill patient presents a significant muscle waste related with the length of stay and the treatment received with muscle relaxants. Patients are being discharged with a similar body weight to which they were admitted but with a significant reduction of muscle mass.

Overview of the Introduction of Neuromuscular Monitoring to Clinical Anaesthesia

Muscle relaxants were introduced into clinical practice in the early 1940s. From 1949, assessments were being made of the efficacy of various agents in awake volunteers, usually the researchers themselves. From the early to mid 1950s, while interest in using muscle relaxants was keen, concern emerged in the surgical literature that there was a higher mortality rate seen in patients receiving muscle relaxants. In fairness, the major article highlighted lack of randomisation, bias and confounding variables but this was largely regarded as showing a toxicity associated with muscle relaxants. By 1961 the matter had been settled that muscle relaxants were not toxic but required careful management and administration. Perhaps fortuitously, measurement of the degree of muscle relaxation was introduced to clinical practice with the use of nerve stimulation. These were measured responses to single twitch stimulus or tetanic stimulation. In 1970, train-of-four ratio was introduced, then in 1981 post-tetanic count, and in 1989 double burst stimulation. This article reviews the introduction of these techniques.