Search results for: analgesia
Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 69

Search results for: analgesia

39 Randomized Controlled Trial of Ultrasound Guided Bilateral Intermediate Cervical Plexus Block in Thyroid Surgery

Authors: Neerja Bharti, Drishya P.

Abstract:

Introduction: Thyroidectomies are extensive surgeries involving a significant degree of tissue handling and dissection and are associated with considerable postoperative pain. Regional anaesthesia techniques have immerged as possible inexpensive and safe alternatives to opioids in the management of pain after thyroidectomy. The front of the neck is innervated by branches from the cervical plexus, and hence, several approaches for superficial and deep cervical plexus block (CPB) have been described to provide postoperative analgesia after neck surgery. However, very few studies have explored the analgesic efficacy of intermediate CPB for thyroid surgery. In this study, we have evaluated the effects of ultrasound-guided bilateral intermediate CPB on perioperative opioid consumption in patients undergoing thyroidectomy under general anesthesia. Methods: In this prospective randomized controlled study, fifty ASA grade I-II adult patients undergoing thyroidectomy were randomly divided into two groups: the study group received ultrasound-guided bilateral intermediate CPB with 10 ml 0.5% ropivacaine on each side, while the control group received the same block with 10 ml normal saline on each side just after induction of anesthesia. Anesthesia was induced with propofol, fentanyl, and vecuronium and maintained with propofol infusion titrated to maintain the BIS between 40 and 60. During the postoperative period, rescue analgesia was provided with PCA fentanyl, and the pain scores, total fentanyl consumption, and incidence of nausea and vomiting during 24 hours were recorded, and overall patient satisfaction was assessed. Results: The groups were well-matched with respect to age, gender, BMI, and duration of surgery. The difference in intraoperative propofol and fentanyl consumption was not statistically significant between groups. However, the intraoperative haemodynamic parameters were better maintained in the study group than in the control group. The postoperative pain scores, as measured by VAS at rest and during movement, were lower, and the total fentanyl consumption during 24 hours was significantly less in the study group as compared to the control group. Patients in the study group reported better satisfaction scores than those in the control group. No adverse effects of ultrasound-guided intermediate CPB block were reported. Conclusion: We concluded that ultrasound-guided intermediate cervical plexus block is a safe and effective method for providing perioperative analgesia during thyroid surgery.

Keywords: thyroidectomy, cervical plexus block, pain relief, opioid consumption

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38 Comparison of Effectiveness When Ketamine was Used as an Adjuvant in Intravenous Patient-Controlled Analgesia Used to Control Cancer Pain

Authors: Donghee Kang

Abstract:

Background: Cancer pain is very difficult to control as the mechanism of pain is varied, and the patient has several co-morbidities. The use of Intravenous Patient-Controlled Analgesia (IV-PCA) can effectively control underlying pain and breakthrough pain. Ketamine is used in many pain patients due to its unique analgesic effect. In this study, it was checked whether there was a difference in the amount of analgesic usage, pain control degree, and side effects between patients who controlled pain with fentanyl-based IV-PCA and those who added Ketamine for pain control. Methods: Among the patients referred to this department for cancer pain, IV-PCA was applied to patients who were taking sufficient oral analgesics but could not control them or had blood clotting disorders that made the procedure difficult, and this patient group was targeted. In IV-PCA, 3000 mcg of Fentanyl, 160 mg of Nefopam, and 0.3 mg of Ramosetrone were mixed with normal saline to make a total volume of 100 ml. Group F used this IV-PCA as it is, and group K mixed 250 mg of Ketamine with normal saline to make a total volume of 100 ml. For IV-PCA, the basal rate was 0.5ml/h, the bolus was set to 1ml when pressed once, and the lockout time was set to 15 minutes. If pain was not controlled after IV-PCA application, 500 mcg of Fentanyl was added, and if excessive sedation or breathing difficulties occurred, the use was stopped for one hour. After that, the degree of daily pain control, analgesic usage, and side effects were investigated for seven days using this IV-PCA. Results: There was no difference between the two groups in the demographic data. Both groups had adequate pain control. Initial morphine milligram equivalents did not differ between the two groups, but the total amount of Fentanyl used for seven days was significantly different between the two groups [p=0.014], and group F used more Fentanyl through IV-PCA. In addition, the amount of sleeping pills used during the seven days was higher in Group F [p<0.01]. Overall, there was no difference in the frequency of side effects between the two groups, but the nausea was more frequent in Group F [p=0.031]. Discussion: When the two groups were compared, pain control was good in both groups. This seems to be because Fentanyl-based IV-PCA showed an adequate pain control effect. However, there was a significant difference in the total amount of opioid (Fentanyl) used, which is thought to be the opioid-sparing effect of Ketamine. Also, among the side effects, nausea was significantly less, which is thought to be possible because the amount of opioids used in the Ketamine group was small. The frequency of requesting sleeping pills was significantly less in the group using Ketamine, and it seems that Ketamine also helped improve sleep quality. In conclusion, using Ketamine with an opioid to control pain seems to have advantages. IV-PCA, which can be used effectively when other procedures are difficult, is more effective and safer when used together with Ketamine than opioids alone.

Keywords: cancer pain, intravenous patient-controlled analgesia, Ketamine, opioid

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37 Post Operative Analgesia after Orthotopic Liver Transplantation; A Clinical Randomized Trial

Authors: Soudeh Tabashi, Mohammadreza Moshari, Parisa Sezari

Abstract:

Introduction: Postoperative analgesia in Orthotopic Liver Transplantation (OLT) surgery is challenging for anesthesiologists. Although OLT is one of the most extensive abdominal operations, it seems that patients don’t suffer from severe post operative pain. On the other hands drug metabolism is unpredictable due to unknown graft function. The aim of this study was to compare intraoperative infusion of remifentanil versus fentanyl in postoperative opioid demand in patients with OLT and evaluating the complications in two groups. Method: In this double-blind clinical trial 34 patients who had OLT were included. They divided randomly in two groups of Remifentanil (R) and Fentanyl (F). Patients in group R and F received infusion of Remifentanil 0.3-1 µg/Kg/min and Fentanyl 0.3-1 µg/Kg/min during maintenance of anesthesia. Post operative pain were measured in 6, 12, 18, 24 hours and second and third days after surgery with Numeric Rate Scale (NRS). Patients had received intravenous acetaminophen as rescue therapy with NRS of 3 or more. In addition to demographic information, post operative opioid consumption were recorded as the primary outcome. Intraoperative blood transfusion, intraoperative inotropic drugs consumption, weaning time and intensive care unit stay were also evaluated. Results: Total dose of acetaminophen consumption in first 3 days after surgery did not have significant difference between two groups (Pvalue=0.716). intraoperative inotrope consumption, blood transfusion and post operative weaning time and ICU stay were also similar in both groups. Conclusion: This study demonstrates that intraoperative infusion of remifentanil in OLT have the same effect on post operative pain management as fentanyl. Despite the complications of operation were not increased by remifentanil.

Keywords: liver transplantation, postoperative pain, remifentanil, fentanyl

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36 Thiopental-Fentanyl versus Midazolam-Fentanyl for Emergency Department Procedural Sedation and Analgesia in Patients with Shoulder Dislocation and Distal Radial Fracture-Dislocation: A Randomized Double-Blind Controlled Trial

Authors: D. Farsi, G. Dokhtvasi, S. Abbasi, S. Shafiee Ardestani, E. Payani

Abstract:

Background and aim:It has not been well studied whether fentanyl-thiopental (FT) is effective and safe for PSA in orthopedic procedures in Emergency Department (ED). The aim of this trial was to evaluate the effectiveness of intravenous FTversusfentanyl-midazolam (FM)in patients who suffered from shoulder dislocation or distal radial fracture-dislocation. Methods:In this randomized double-blinded study, Seventy-six eligible patients were entered the study and randomly received intravenous FT or FM. The success rate, onset of action and recovery time, pain score, physicians’ satisfaction and adverse events were assessed and recorded by treating emergency physicians. The statistical analysis was intention to treat. Results: The success rate after administrating loading dose in FT group was significantly higher than FM group (71.7% vs. 48.9%, p=0.04); however, the ultimate unsuccess rate after 3 doses of drugs in the FT group was higher than the FM group (3 to 1) but it did not reach to significant level (p=0.61). Despite near equal onset of action time in two study group (P=0.464), the recovery period in patients receiving FT was markedly shorter than FM group (P<0.001). The occurrence of adverse effects was low in both groups (p=0.31). Conclusion: PSA using FT is effective and appears to be safe for orthopedic procedures in the ED. Therefore, regarding the prompt onset of action, short recovery period of thiopental, it seems that this combination can be considered more for performing PSA in orthopedic procedures in ED.

Keywords: procedural sedation and analgesia, thiopental, fentanyl, midazolam, orthopedic procedure, emergency department, pain

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35 Effect of Oral Clonidine Premedication on Subarachnoid Block Characteristics of 0.5 % Hyperbaric Bupivacaine for Laparoscopic Gynecological Procedures – A Randomized Control Study

Authors: Buchh Aqsa, Inayat Umar

Abstract:

Background- Clonidine, α 2 agonist, possesses several properties to make it valuable adjuvant for spinal anesthesia. The study was aimed to evaluate the clinical effects of oral clonidine premedication for laparoscopic gynecological procedures under subarachnoid block. Patients and method- Sixtyfour adult female patients of ASA physical status I and II, aged 25 to 45 years and scheduled for laparoscopic gynecological procedures under the subarachnoid block, were randomized into two comparable equal groups of 32 patients each to received either oral clonidine, 100 µg (Group I) or placebo (Group II), 90 minutes before the procedure. Subarachnoid block was established with of 3.5 ml of 0.5% hyperbaric bupivacaine in all patients. Onset and duration of sensory and motor block, maximum cephalad level, and the regression time to reach S1 sensory level were assessed as primary end points. Sedation, hemodynamic variability, and respiratory depression or any other side effects were evaluated as secondary outcomes. Results- The demographic profile was comparable. The intraoperative hemodynamic parameters showed significant differences between groups. Oral clonidine was accelerated the onset time of sensory and motor blockade and extended the duration of sensory block (216.4 ± 23.3 min versus 165 ± 37.2 min, P <0.05). The duration of motor block showed no significant difference. The sedation score was more than 2 in the clonidine group as compared to the control group. Conclusion- Oral clonidine premedication has extended the duration of sensory analgesia with arousable sedation. It also prevented the post spinal shivering of the subarachnoid block.

Keywords: oral clonidine, subarachnoid block, sensory analgesia, laparoscopic gynaecological

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34 Comparison of Regional and Local Indwelling Catheter Techniques to Prolong Analgesia in Total Knee Arthroplasty Procedures: Continuous Peripheral Nerve Block and Continuous Periarticular Infiltration

Authors: Jared Cheves, Amanda DeChent, Joyce Pan

Abstract:

Total knee replacements (TKAs) are one of the most common but painful surgical procedures performed in the United States. Currently, the gold standard for postoperative pain management is the utilization of opioids. However, in the wake of the opioid epidemic, the healthcare system is attempting to reduce opioid consumption by trialing innovative opioid sparing analgesic techniques such as continuous peripheral nerve blocks (CPNB) and continuous periarticular infiltration (CPAI). The alleviation of pain, particularly during the first 72 hours postoperatively, is of utmost importance due to its association with delayed recovery, impaired rehabilitation, immunosuppression, the development of chronic pain, the development of rebound pain, and decreased patient satisfaction. While both CPNB and CPAI are being used today, there is limited evidence comparing the two to the current standard of care or to each other. An extensive literature review was performed to explore the safety profiles and effectiveness of CPNB and CPAI in reducing reported pain scores and decreasing opioid consumption. The literature revealed the usage of CPNB contributed to lower pain scores and decreased opioid use when compared to opioid-only control groups. Additionally, CPAI did not improve pain scores or decrease opioid consumption when combined with a multimodal analgesic (MMA) regimen. When comparing CPNB and CPAI to each other, neither unanimously lowered pain scores to a greater degree, but the literature indicates that CPNB decreased opioid consumption more than CPAI. More research is needed to further cement the efficacy of CPNB and CPAI as standard components of MMA in TKA procedures. In addition, future research can also focus on novel catheter-free applications to reduce the complications of continuous catheter analgesics.

Keywords: total knee arthroplasty, continuous peripheral nerve blocks, continuous periarticular infiltration, opioid, multimodal analgesia

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33 A Randomized Active Controlled Clinical Trial to Assess Clinical Efficacy and Safety of Tapentadol Nasal Spray in Moderate to Severe Post-Surgical Pain

Authors: Kamal Tolani, Sandeep Kumar, Rohit Luthra, Ankit Dadhania, Krishnaprasad K., Ram Gupta, Deepa Joshi

Abstract:

Background: Post-operative analgesia remains a clinical challenge, with central and peripheral sensitization playing a pivotal role in treatment-related complications and impaired quality of life. Centrally acting opioids offer poor risk benefit profile with increased intensity of gastrointestinal or central side effects and slow onset of clinical analgesia. The objective of this study was to assess the clinical feasibility of induction and maintenance therapy with Tapentadol Nasal Spray (NS) in moderate to severe acute post-operative pain. Methods: Phase III, randomized, active-controlled, non-inferiority clinical trial involving 294 cases who had undergone surgical procedures under general anesthesia or regional anesthesia. Post-surgery patients were randomized to receive either Tapentadol NS 45 mg or Tramadol 100mg IV as a bolus and subsequent 50 mg or 100 mg dose over 2-3 minutes. The frequency of administration of NS was at every 4-6 hours. At the end of 24 hrs, patients in the tramadol group who had a pain intensity score of ≥4 were switched to oral tramadol immediate release 100mg capsule until the pain intensity score reduced to <4. All patients who had achieved pain intensity ≤ 4 were shifted to a lower dose of either Tapentadol NS 22.5 mg or oral Tramadol immediate release 50mg capsule. The statistical analysis plan was envisaged as a non-inferiority trial involving comparison with Tramadol for Pain intensity difference at 60 minutes (PID60min), Sum of Pain intensity difference at 60 minutes (SPID60min), and Physician Global Assessment at 24 hrs (PGA24 hrs). Results: The per-protocol analyses involved 255 hospitalized cases undergoing surgical procedures. The median age of patients was 38.0 years. For the primary efficacy variables, Tapentadol NS was non-inferior to Inj/Oral Tramadol in relief of moderate to severe post-operative pain. On the basis of SPID60min, no clinically significant difference was observed between Tapentadol NS and Tramadol IV (1.73±2.24 vs. 1.64± 1.92, -0.09 [95% CI, -0.43, 0.60]). In the co-primary endpoint PGA24hrs, Tapentadol NS was non–inferior to Tramadol IV (2.12 ± 0.707 vs. 2.02 ±0.704, - 0.11[95% CI, -0.07, 0.28). However, on further assessment at 48hr, 72 hrs, and 120hrs, clinically superior pain relief was observed with the Tapentadol NS formulation that was statistically significant (p <0.05) at each of the time intervals. Secondary efficacy measures, including the onset of clinical analgesia and TOTPAR, showed non-inferiority to Tramadol. The safety profile and need for rescue medication were also similar in both the groups during the treatment period. The most common concomitant medications were anti-bacterial (98.3%). Conclusion: Tapentadol NS is a clinically feasible option for improved compliance as induction and maintenance therapy while offering a sustained and persistent patient response that is clinically meaningful in post-surgical settings.

Keywords: tapentadol nasal spray, acute pain, tramadol, post-operative pain

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32 Study on the Effect of Pre-Operative Patient Education on Post-Operative Outcomes

Authors: Chaudhary Itisha, Shankar Manu

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Patient satisfaction represents a crucial aspect in the evaluation of health care services. Preoperative teaching provides the patient with pertinent information concerning the surgical process and the intended surgical procedure as well as anticipated patient behavior (anxiety, fear), expected sensation, and the probable outcomes. Although patient education is part of Accreditation protocols, it is not uniform at most places. The aim of this study was to try to assess the benefit of preoperative patient education on selected post-operative outcome parameters; mainly, post-operative pain scores, requirement of additional analgesia, return to activity of daily living and overall patient satisfaction, and try to standardize few education protocols. Dependent variables were measured before and after the treatment on a study population of 302 volunteers. Educational intervention was provided by the Investigator in the preoperative period to the study group through personal counseling. An information booklet contained detailed information was also provided. Statistical Analysis was done using Chi square test, Mann Whitney u test and Fischer Exact Test on a total of 302 subjects. P value <0.05 was considered as level of statistical significance and p<0.01 was considered as highly significant. This study suggested that patients who are given a structured, individualized and elaborate preoperative education and counseling have a better ability to cope up with postoperative pain in the immediate post-operative period. However, there was not much difference when the patients have had almost complete recovery. There was no difference in the requirement of additional analgesia among the two groups. There is a positive effect of preoperative counseling on expected return to the activities of daily living and normal work schedule. However, no effect was observed on the activities in the immediate post-operative period. There is no difference in the overall satisfaction score among the two groups of patients. Thus this study concludes that there is a positive benefit as suggested by the results for pre-operative patient education. Although the difference in various parameters studied might not be significant over a long term basis, they definitely point towards the benefits of preoperative patient education. 

Keywords: patient education, post-operative pain, postoperative outcomes, patient satisfaction

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31 Partnering With Key Stakeholders for Successful Implementation of Inhaled Analgesia for Specific Emergency Department Presentations

Authors: Sarah Hazelwood, Janice Hay

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Methoxyflurane is an inhaled analgesic administered via a disposable inhaler, which has been used in Australia for 40 years for the management of pain in children & adults. However, there is a lack of data for methoxyflurane as a frontline analgesic medication within the emergency department (ED). This study will investigate the usefulness of methoxyflurane in a private inner-city ED. The study concluded that the inclusion of all key stakeholders in the prescribing, administering & use of this new process led to comprehensive uptake & vastly positive outcomes for consumer & health professionals. Method: A 12-week prospective pilot study was completed utilizing patients presenting to the ED in pain (numeric pain rating score > 4) that fit the requirement of methoxyflurane use (as outlined in the Australian Prescriber information package). Nurses completed a formatted spreadsheet for each interaction where methoxyflurane was used. Patient demographics, day, time, initial numeric pain score, analgesic response time, the reason for use, staff concern (free text), & patient feedback (free text), & discharge time was documented. When clinical concern was raised, the researcher retrieved & reviewed patient notes. Results: 140 methoxyflurane inhalers were used. 60% of patients were 31 years of age & over (n=82) with 16% aged 70+. The gender split; 51% male: 49% female. Trauma-related pain (57%) saw the highest use of administration, with the evening hours (1500-2259) seeing the greatest numbers used (39%). Tuesday, Thursday & Sunday shared the highest daily use throughout the study. A minimum numerical pain score of 4/10 (n=13, 9%), with the ranges of 5 - 7/10 (moderate pain) being given by almost 50% of patients. Only 3 instances of pain scores increased post use of methoxyflurane (all other entries showed pain score < initial rating). Patients & staff noted obvious analgesic response within 3 minutes (n= 96, 81%, of administration). Nurses documented a change in patient vital signs for 4 of the 15 patient-related concerns; the remaining concerns were due to “gagging” on the taste, or “having a coughing episode”; one patient tried to leave the department before the procedure was attended (very euphoric state). Upon review of the staff concerns – no adverse events occurred & return to therapeutic vitals occurred within 10 minutes. Length of stay for patients was compared with similar presentations (such as dislocated shoulder or ankle fracture) & saw an average 40-minute decrease in time to discharge. Methoxyflurane treatment was rated “positively” by > 80% of patients – with remaining feedback related to mild & transient concerns. Staff similarly noted a positive response to methoxyflurane as an analgesic & as an added tool for frontline analgesic purposes. Conclusion: Methoxyflurane should be used on suitable patient presentations requiring immediate, short term pain relief. As a highly portable, non-narcotic avenue to treat pain this study showed obvious therapeutic benefit, positive feedback, & a shorter length of stay in the ED. By partnering with key stake holders, this study determined methoxyflurane use decreased work load, decreased wait time to analgesia, and increased patient satisfaction.

Keywords: analgesia, benefits, emergency, methoxyflurane

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30 Hilotherapy in Orthognathic Surgery

Authors: N. Gharooni-Dowrani, B. Gharooni-Dowrani

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The benefits of hilotherapy following orthogonathic surgery have been explored in recent years, demonstrating reduction in patient pain and swelling post-operatively. However, hilotherapy is not always widely accessible to all patients following orthognathic surgery. In this study, 50 patients were examined at Luton and Dunstable Hospital, half (25) of which used hilotherm masks post operatively and half of which opted for traditional ice packs in order to aid recovery. This study demonstrated that the use of hilotherapy reduced patient pain when analgesia need and use were analysed, as well as shortening inpatient stay. Although no current hilotherm masks are available without rental services in our trust, this study demonstrated the positive outcomes that they may bring, which may be worth future investment for our department.

Keywords: orthognathic surgery, orthodontics, hilotherapy, OMFS

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29 The Emerging Role of Cannabis as an Anti-Nociceptive Agent in the Treatment of Chronic Back Pain

Authors: Josiah Damisa, Michelle Louise Richardson, Morenike Adewuyi

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Lower back pain is a significant cause of disability worldwide and associated with great implications in terms of the well-being of affected individuals and society as a whole due to its undeniable socio-economic impact. With its prevalence on the increase as a result of an aging global population, the need for novel forms of pain management is ever paramount. This review aims to provide further insight into current research regarding a role for the endocannabinoid signaling pathway as a target in the treatment of chronic pain, with particular emphasis on its potential use as part of the treatment of lower back pain. Potential advantages and limitations of cannabis-based medicines over other forms of analgesia currently licensed for medical use are discussed in addition to areas that require ongoing consideration and research. To evaluate the efficacy of cannabis-based medicines in chronic pain, studies pertaining to the role of medical cannabis in chronic disease were reviewed. Standard searches of PubMed, Google Scholar and Web of Science databases were undertaken with peer-reviewed journal articles reviewed based on the indication for pain management, cannabis treatment modality used and study outcomes. Multiple studies suggest an emerging role for cannabis-based medicines as therapeutic agents in the treatment of chronic back pain. A potential synergistic effect has also been purported if these medicines are co-administered with opiate analgesia due to the similarity of the opiate and endocannabinoid signaling pathways. However, whilst recent changes to legislation in the United Kingdom mean that cannabis is now licensed for medicinal use on NHS prescription for a number of chronic health conditions, concerns remain as to the efficacy and safety of cannabis-based medicines. Research is lacking into both their side effect profiles and the long-term effects of cannabis use. Legal and ethical considerations to the use of these products in standardized medical practice also persist due to the notoriety of cannabis as a drug of abuse. Despite this, cannabis is beginning to gain traction as an alternative or even complementary drug to opiates, with some preclinical studies showing opiate-sparing effects. Whilst there is a paucity of clinical trials in this field, there is scope for cannabinoids to be successful anti-nociceptive agents in managing chronic back pain. The ultimate aim would be to utilize cannabis-based medicines as alternative or complementary therapies, thereby reducing opiate over-reliance and providing hope to individuals who have exhausted all other forms of standard treatment.

Keywords: endocannabinoids, cannabis-based medicines, chronic pain, lower back pain

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28 Investigating the Dose Effect of Electroacupuncture on Mice Inflammatory Pain Model

Authors: Wan-Ting Shen, Ching-Liang Hsieh, Yi-Wen Lin

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Electroacupuncture (EA) has been reported effective for many kinds of pain and is a common treatment for acute or chronic pain. However, to date, there are limited studies examining the effect of acupuncture dosage. In our experiment, after injecting mice with Complete Freund’s Adjuvant (CFA) to induce inflammatory pain, two groups of mice were administered two different 15 min EA treatments at 2Hz. The first group received EA at a single acupuncture point (ST36, Zusanli) in both legs (two points), whereas the second group received two acupuncture points in both legs (four points) and the analgesic effect was compared. It was found that double points (ST36, Zusanli and SP6, Sanyinjiao) were significantly superior to single points (ST36, Zusanli) when evaluated using the electronic von Frey Test (mechanic) and Hargreaves’ Test (thermal). Through this study, it is expected more novel physiological mechanisms of acupuncture analgesia will be discovered.

Keywords: anti-inflammation, dose effect, electroacupuncture, pain control

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27 Palliation of Pain in Pyomyositis: A Case Series and Literature Review

Authors: Katie Jerram, Jacqui Nevols, Rebecca Howes, Hayley Richardson, Debbie Suso, Thomas Batten, Reny Mathai

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Pyomyositis is an uncommon acute purulent skeletal muscle infection, usually caused by Staphylococcus aureus, occurring either spontaneously or following local trauma. Immunocompromise is a risk factor. It presents with pyrexia, pain, and tenderness of the affected muscle, which may have a firm ‘woody’ feel. Management usually involves surgery and prolonged courses of antibiotics, but alongside these active treatments, palliation of symptoms such as pain is also a priority. A short case series of diabetic inpatients under the care of the Renal Medicine team with pyomyositis is presented, demonstrating that Hospital Palliative Care Teams may be well placed to provide symptom management advice by working jointly with the patient’s medical or surgical team. A review of the literature on the management of pain in pyomyositis is also presented, and there was no clear consensus on the best strategy. It may be that a combination of analgesics and adjuncts is the most effective strategy, perhaps combined with the holistic approach used within palliative care.

Keywords: pyomyositis, pain, palliation, analgesia

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26 The Use of Regional Blocks Versus IV Opioid Analgesics for Acute Traumatic Pain Management in the Emergency Department

Authors: Lajeesh Jabbar, Shibu T. Varghese

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Being under pain is a very distressing factor that it prolongs the healing of any kind of trauma and add to the post traumatic stressful state. Alleviating the pain from acute traumatic conditions like fracture, degloving injury etc will help in faster recovery and also decrease the incidence of post traumatic stress disorder. Most of the emergency departments in INDIA are using IV opioid analgesics to relieve the patient from pain in cases of acute traumatic injuries. None of the Emergency Departments practice regional blocks in the country. In this study, we are comparing the efficacy of Regional Blocks in relieving the pain in lower limb fractures versus the use of IV analgesics for the same in the emergency department. The site of study is Malabar Institute Of Medical Sciences in Calicut in Kerala in India and is a place which receives approximately 10-20 traumatic fracture cases per day. The fracture sites used for the study purpose are femur fracture and phalangeal fractures.

Keywords: regional blocks, IV analgesia, acute traumatic pain, femur fractures, phalanx fractures

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25 Efficacy and Safety of Sublingual Sufentanil for the Management of Acute Pain

Authors: Neil Singla, Derek Muse, Karen DiDonato, Pamela Palmer

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Introduction: Pain is the most common reason people visit emergency rooms. Studies indicate however, that Emergency Department (ED) physicians often do not provide adequate analgesia to their patients as a result of gender and age bias, opiophobia and insufficient knowledge of and formal training in acute pain management. Novel classes of analgesics have recently been introduced, but many patients suffer from acute pain in settings where the availability of intravenous (IV) access may be limited, so there remains a clinical need for rapid-acting, potent analgesics that do not require an invasive route of delivery. A sublingual sufentanil tablet (SST), dispensed using a single-dose applicator, is in development for treatment of moderate-to-severe acute pain in a medically-supervised setting. Objective: The primary objective of this study was to demonstrate the repeat-dose efficacy, safety and tolerability of sufentanil 20 mcg and 30 mcg sublingual tablets compared to placebo for the management of acute pain as determined by the time-weighted sum of pain intensity differences (SPID) to baseline over the 12-hour study period (SPID12). Key secondary efficacy variables included SPID over the first hour (SPID1), Total pain relief over the 12-hour study period (TOTPAR12), time to perceived pain relief (PR) and time to meaningful PR. Safety variables consisted of adverse events (AE), vital signs, oxygen saturation and early termination. Methods: In this Phase 2, double-blind, dose-finding study, an equal number of male and female patients were randomly assigned in a 2:2:1 ratio to SST 20 mcg, SS 30 mcg or placebo, respectively, following bunionectomy. Study drug was dosed as needed, but not more frequently than hourly. Rescue medication was available as needed. The primary endpoint was the Summed Pain Intensity Difference to baseline over 12h (SPIDI2). Safety was assessed by continuous oxygen saturation monitoring and adverse event reporting. Results: 101 patients (51 Male/50 Female) were randomized, 100 received study treatment (intent-to-treat [ITT] population), and 91 completed the study. Reasons for early discontinuation were lack of efficacy (6), adverse events (2) and drug-dosing error (1). Mean age was 42.5 years. For the ITT population, SST 30 mcg was superior to placebo (p=0.003) for the SPID12. SPID12 scores in the active groups were superior for both male (ANOVA overall p-value =0.038) and female (ANOVA overall p-value=0.005) patients. Statistically significant differences in favour of sublingual sufentanil were also observed between the SST 30mcg and placebo group for SPID1(p<0.001), TOTPAR12(p=0.002), time to perceived PR (p=0.023) and time to meaningful PR (p=0.010). Nausea, vomiting and somnolence were more frequent in the sufentanil groups but there were no significant differences between treatment arms for the proportion of patients who prematurely terminated due to AE or inadequate analgesia. Conclusions: Sufentanil tablets dispensed sublingually using a single-dose applicator is in development for treatment of patients with moderate-to-severe acute pain in a medically-supervised setting where immediate IV access is limited. When administered sublingually, sufentanil’s pharmacokinetic profile and non-invasive delivery makes it a useful alternative to IM or IV dosing.

Keywords: acute pain, pain management, sublingual, sufentanil

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24 Pain Control by Ketamine in Combat Situation; Consideration and Outcomes

Authors: Mohammad Javad Behzadnia, Hamidreza Javadzadeh

Abstract:

Background: Pain management is essential to surmounting multi-injured people in an overcrowded emergency setting. Its role would be more apparent when the physician encounters a mass casualty in a war zone or even a military prehospital. Having sedative and analgesic properties, rapid onset and offset effects, and maintaining the cardiovascular and respiratory contain are the main reason for selecting Ketamine as a good choice in the war zone. Methods: In a prospective interventional study in a war zone, we have selected and followed two groups of casualties for pain management. All were men with an average age of 26.6±8 y/o and 27.5 ±7 y/o in A and B groups, respectively. Group A received only Ketamine and Group B received Ketamine and diazepam. Results: This study showed that all of the injured patients who received Ketamine had experienced some agitation, and they may finally need benzodiazepines for sedation, but in group B that received benzodiazepine before or simultaneous with Ketamine, the agitation was significantly reduced. (P Value ≤0.05) Conclusion: Various factors may affect pain score and perception; patients' culture, mental health, previous drug usage, and addiction could alter the pain score in similar situations. It seems that the significant agitation is due to catecholamine release in stressful Moments of the battlefield. Accordingly, this situation could be exacerbated due to ketamine properties. Nonetheless, as a good choice in the war zone, Ketamine is now recommended to combine with benzodiazepines for procedural sedation and analgesia (PSA).

Keywords: battlefield, ketamine, benzodiazepine, pain control

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23 Temporary Ureteric Catheterization after Ureteropyeloscopy: Experience from Regional Australia

Authors: Jake Tempo, Jack Crozier, Huay Ann Chia, Philip Tan

Abstract:

Purpose: A prospective study was performed to determine whether temporary ureteric catheterization should be eliminated as a prophylactic method for preventing ureteric obstruction after uncomplicated ureteropyeloscopic lithotripsy. Material and Methods: From 2010 to 2014, 227 patients underwent uncomplicated ureteroscopic and/or pyeloscopic lithotripsy. Three patient-groups based on postoperative drainage method were analysed: temporary uretericcatheter (TUC), -ureteric JJ stent, and no-stent groups. Exclusion criteria included urosepsis, ureteric injury, and non-surgical complications delaying hospital-discharge. Outcome measures included parenteral analgesic requirements, prolonged hospitalization ≥2 days due to postoperative-pain, and readmissions rate. Results: Delayed discharge was reported in 14.5%(9 of 62) patients in the TUC group compared to 3.4%(4 of 119) in theureteric JJ stent group and 8.7%(4 of 46) in the no-drainage-group (p=0.02). Odds ratio for delayed-discharge between catheter- versus-ureteric JJ stent is 4.9 (95% CI = 1.6-15.0; p < 0.01). Parenteral analgesic requirements in the TUC group (12.9%) was also significantly higher than theureteric JJ stent group (1.7%; p=0.003). Readmissions were negligible between groups. Conclusions: Patients with ureteric catheters after uncomplicated ureteroscopy have a prolonged hospital stay with increased pain and parenteral analgesic requirements. There is a 7.6-fold increased requirement for parenteral analgesia and a 4.2-fold increased risk of delayed-discharge compared to a patient with a ureteric JJ stent.

Keywords: ureteric catheter, ureteric stent, ureteroscopy, pyeloscopy

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22 Role of Transient Receptor Potential Vanilloid 1 in Electroacupuncture Analgesia on Chronic Inflammatory Pain in Mice

Authors: Jun Yang, Ching-Liang Hsieh, Yi-Wen Lin

Abstract:

Chronic inflammatory pain results from peripheral tissue injury or local inflammation to increase the release of protons, histamines, adenosine triphosphate, and several proinflammatory cytokines. Transient receptor potential vanilloid 1 (TRPV1) is involved in fibromyalgia, neuropathic, and inflammatory pain; however, its exact mechanisms in chronic inflammatory pain are still unclear. We investigate the analgesic effect of EA by injecting complete Freund’s adjuvant (CFA) in the hind paw of mice to induce chronic inflammatory pain ( > 14 d). Our results showed that EA significantly reduced chronic mechanical and thermal hyperalgesia in the chronic inflammatory pain model. Chronic mechanical and thermal hyperalgesia was also abolished in TRPV1−/− mice. TRPV1 increased in the dorsal root ganglion (DRG) and spinal cord (SC) at 2 weeks after CFA injection. The expression levels of downstream molecules such as pPKA, pPI3K, and pPKC increased, as did those of pERK, pp38, and pJNK. Transcription factors (pCREB and pNFκB) and nociceptive ion channels (Nav1.7 and Nav1.8) were involved in this process. Inflammatory mediators such as GFAP (Glial fibrillary acidic protein), S100B, and RAGE (Receptor for advanced glycation endproducts) were also involved. The expression levels of these molecules were reduced in EA (electroacupuncture) and TRPV1−/−mice but not in the sham EA group. The present study demonstrated that EA or TRPV1 gene deletion reduced chronic inflammatory pain through TRPV1 and related molecules. In addition, our data provided evidence to support the clinical use of EA for treating chronic inflammatory pain.

Keywords: auricular electric-stimulation, epileptic seizures, anti-inflammation, electroacupuncture

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21 Acupoint Injection of High Concentration of Glucose Attenuates Mice Chronic Pain and Depression Comorbidity

Authors: Chanya Inprasit, Yi-Wen Lin

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Inflammation causes changes of peripheral and central nervous system properties, affecting both neuronal and non-neuronal cells, resulting in inflammatory pain. Acupoint injection (AI) was developed in the 1950s and has been widely used for relieving pain. It is an acupoint-stimulating technique that utilizes anatomically based meridians derived from Chinese medicine theory. AI has been accepted as an effective treatment and is thought to display superior results when compared to traditional acupuncture methods. However, the mechanism of AI needs to be ratified by more scientific evidence in order to support the theory and its therapeutic development. In this study, we explored the effect of AI on the comorbidity of chronic pain and depression. Mice hindpaw was injected by complete Freund’s adjuvant (CFA) to induce the condition of chronic pain. Measurements of mechanical and thermal hyperalgesia and depression-like behavior were analyzed. The results indicated a positive tendency to AI treatment. The comorbidity of chronic pain and depression was investigated with relation to transient receptor potential V1 (TRPV1) mechanism through the use of TRPV1 gene deletion. The expression of nociceptors such as voltage-gated sodium channels (Navs) or TRPV1, was significantly down-regulated by AI. The expression of inflammation-activated molecules: astrocytic marker glial fibrillary acidic protein (GFAP), the microglial marker Iba-1, S100B, and related kinases, were reversed by AI in both the peripheral and central nervous system. Taken together, these data provided a detailed molecular mechanism of AI-induced analgesia and anti-inflammatory properties. This finding may be utilized for clinical practice to treat chronic pain and depression comorbidity.

Keywords: inflammatory pain, acupoint injection, TRPV1, GFAP, S100B

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20 Reduction of Transient Receptor Potential Vanilloid 1 for Chronic Pain and Depression Co-Morbidity through Electroacupuncture and Gene Deletion in Mice Brain

Authors: Bernice Lottering, Yi-Wen Lin

Abstract:

Chronic pain and depression have an estimated 80% rate of comorbidity with unsatisfactory treatment interventions signifying the importance of developing effective therapeutic interventions for a serious chronic condition affecting a large majority of the global population. Chronic pain is defined as persistent pain presenting for over 3 months. This disease state increases the risk of developing depression in comparison to healthy individuals. In the current study, complete Freund’s adjuvant (CFA) was used to induce cell-mediated chronic inflammatory pain in a murine model. Significant mechanical and thermal hyperalgesia was induced, alongside observable depression-like behaviors. These conditions were attenuated through the use of electroacupuncture (EA). Similarly, these effects were also investigated with respect to the transient receptor potential vanilloid 1 (TRPV1), by analyzing the effects of TRPV1 gene deletion on the comorbidity of chronic pain and depression. The expression of the TRPV1 inflammatory response, and related downstream molecules, including protein kinases (PKs), mitogen-activated protein kinase (MAPKs), and transcriptional factors, were significantly reduced in the thalamus, prefrontal cortex (PFC), hippocampus, and periaqueductal gray (PAG) of CFA-treated mice. In addition, phosphorylated N-methyl-D-aspartate (NMDA) receptor 1 was also found to be reduced in the aforementioned areas, suggesting potential application and validity in a clinical setting. Our study determined the prospective therapeutic effects of EA in the treatment of chronic inflammatory pain and depression comorbidity and provides a novel and detailed mechanism underlying EA-mediated analgesia. These findings may be relevant in the utilization of clinical intervention approaches related to chronic pain and depression comorbidity.

Keywords: chronic pain, depression, NMDA, prefrontal cortex, TRPV1

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19 Post-Operative Pain Management in Ehlers-Danlos Hypermobile-Type Syndrome Following Wisdom Teeth Extraction: A Case Report and Literature Review

Authors: Aikaterini Amanatidou

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We describe the case of a 20-year-old female patient diagnosed with Ehlers-Danlos Syndrome (EDS) who was scheduled to undergo a wisdom teeth extraction in outpatient surgery. EDS is a hereditary connective tissue disorder characterized by joint hypermobility, skin hyper-extensibility, and vascular and soft tissue fragility. There are six subtypes of Ehlers-Danlos, and in our case, the patient had EDS hyper-mobility (HT) type disorder. One important clinical feature of this syndrome is chronic pain, which is often poorly understood and treated. Our patient had a long history of articular and lumbar pain when she was diagnosed. She was prescribed analgesic treatment for acute and neuropathic pain and had multiple sessions of psychotherapy and physiotherapy to ease the pain. Unfortunately, her extensive medical history was underrated by our anesthetic team, and no further measures were taken for the operation. Despite an uneventful intra-operative phase, the patient experienced several episodes of hyperalgesia during the immediate post-operative care. Management of pain was challenging for the anesthetic team: initial opioid treatment had only a temporary effect and a paradoxical reaction after a while. Final pain relief was eventually obtained with psycho-physiologic treatment, high doses of ketamine, and patient-controlled analgesia infusion of morphine-ketamine-dehydrobenzperidol. We suspected an episode of Opioid-Induced hyperalgesia. This case report supports the hypothesis that anti-hyperalgesics such as ketamine as well as lidocaine, and dexmedetomidine should be considered intra-operatively to avoid opioid-induced hyperalgesia and may be an alternative solution to manage complex chronic pain like others in neuropathic pain syndromes.

Keywords: Ehlers-Danlos, post-operative management, hyperalgesia, opioid-induced hyperalgesia, rare disease

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18 Use of Alternative and Complementary Therapies in Patients with Chronic Pain in a Medical Institution in Medellin, Colombia, 2014

Authors: Lina María Martínez Sánchez, Juliana Molina Valencia, Esteban Vallejo Agudelo, Daniel Gallego González, María Isabel Pérez Palacio, Juan Ricardo Gaviria García, María De Los Ángeles Rodríguez Gázquez, Gloria Inés Martínez Domínguez

Abstract:

Alternative and complementary therapies constitute a vast and complex combination of interventions, philosophies, approaches, and therapies that acquire a holistic healthcare point of view, becoming an alternative for the treatment of patients with chronic pain. Objective: determine the characteristics of the use of alternative and complementary therapies in patients with chronic pain who consulted in a medical institution. Methodology: cross-sectional and descriptive study, with a population of patients that assisted to the outpatient consultation and met the eligibility criteria. Sampling was not conducted. A form was used for the collection of demographic and clinical variables and the Holistic Complementary and Alternative Medicine Questionnaire (HCAMQ) was validated. The analysis and processing of information was carried out using the SPSS program vr.19. Results: 220 people with chronic pain were included. The average age was 54.7±16.2 years, 78.2% were women, and 75.5% belonged to the socioeconomic strata 1 to 3. Musculoskeletal pain (77.7%), migraine (15%) and neuralgia (9.1%) were the most frequently types of chronic pain. 33.6% of participants have used some kind of alternative and complementary therapy; the most frequent were: homeopathy (14.5%), phytotherapy (12.7%), and acupuncture (11.4%). The total average HCAMQ score for the study group was 30.2±7.0 points, which shows a moderate attitude toward the use of complementary and alternative medicine. The highest scores according to the type of pain were: neuralgia (32.4±5.8), musculoskeletal pain (30.5±6.7), fibromyalgia (29.6±7.3) and migraine (28.5±8.8). The reliability of the HCAMQ was acceptable (Cronbach's α: 0.6). Conclusion: it was noted that the types of chronic pain and the clinical or therapeutic management of patients correspond to the data available in current literature. Despite the moderate attitude toward the use of these alternative and complementary therapies, one of every three patients uses them.

Keywords: chronic pain, complementary therapies, homeopathy, acupuncture analgesia

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17 Raw Japanese Quail Egg Produces Analgesic, Anti-Inflammatory and Gastro-Protective Effects in Rats

Authors: Sani Ismaila, Shafiu Yau, Abubakar Salisu, Buhari Salisu, Sharifat Balogun, Mustapha Abubakar, Biobaku Khalid, Agaie Bello

Abstract:

Over the years, Japanese quail egg has been in use in the management of diseases. The objective of this study was to evaluate the analgesic, anti-inflammatory and gastroprotective effects of raw Quail egg (yolk + albumin) in rats. Pain was assessed in rats by recording the latent period and writing reflex, anti-inflammatory effect was determined using both motility and compression test, while the gastro-protective effects were assessed by observing the histology of the stomach after diclofenac-induced gastric ulcers and subsequent treatment with the quail egg, Rats were randomly assigned into 4 groups; Groups I: were the control non-treated (NT), Group II were treated with Tramadol 50 mg/kg/Os (TMD) or Indomethacin (IND) 5mg/kg/Os (positive control for the writhing reflex determination), while group III and IV were treated with 3 and 6g/kg of raw quail egg respectively). Groups treated with quail egg in both doses showed a significant increase in the latent period (p <0 .05) when compared to the control NT, but lower than the group treated with tramadol at 20mins interval (p<0.05). Writing reflexes decrease in groups II, III, and IV compared to the NT group (p < 0.05). While motility increases significantly (p < 0.05) in groups II, compared to I (p<0.05). Control non-treated rats showed a quicker and extensive response to compression using the Vanier calliper on the inflamed paw compared to groups II-IV (p < 0.05). Histological studies of the stomach revealed sloughing of the epithelia, cellular infiltration with micro abscesses in the non-treated, while groups treated concurrently with quail egg showed proliferation of the glandular epithelia and goblet cells, and those treated 30 minutes before diclofenac administration showed proliferation of glands and thickening of the squamous epithelia. This study showed that quail egg has analgesic, anti-inflammatory and gastro-protective potentials and can be used as adjuvant treatment whenever COX-2 enzymes inhibitors are indicated.

Keywords: analgesia, anti-inflammatory, gastroprotective effect, japanese quail egg

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16 Comparative Study of Analgesic Efficacy of Ultrasound Guided Femoral Nerve Block Versus Intravenous Fentanyl Injection in Fracture Femur Patients at Emergency Department

Authors: Asmaa Hamdy, Israa Nassar, Tarek Aly

Abstract:

Introduction: Femoral fractures are the most common presentation in the Emergency Department (ED), and they can present as isolated injuries or as part of a polytrauma situation. To provide optimum pain management care to these patients, practitioners must be well prepared and current with utilizing modern evidence-based knowledge and practices. Management of pain associated with fracture femur in the emergency department has a critical role in the satisfaction of patients and preventing further complications. This study aimed to evaluate the analgesic efficacy of ultrasound-guided femoral nerve block compared with intravenous fentanyl in fractures of the femur in patients presented to the Emergency Department. Patients and Methods: Fifty patients with femur fractures were divided into two groups: Group A: In this group (twenty-five patients) were given intravenous fentanyl 2 micro-grams/kg and re-assessed for pain by Visual Analogue Score (VAS). Group B: In this group (twenty-five patients) underwent ultrasonography-guided femoral nerve block and were re-assessed for pain by VAS. Results: VAS score on the movement of the fractured limb between group A and group B at a 10-minute post-intervention period shows P= 0.043, and hence the difference is significant. VAS score on the movement of the fractured limb between group A and group B during a 10-minute post-intervention period showed a significant difference. Seventeen patients in group A had major PID with a percentage of 63% VS 10 patients in group B with a percentage of 37%. conclusion: both femoral nerve block and intravenous fentanyl are effective in relieving pain in patients with femur fractures. But femoral nerve block provides better and more intense analgesia and major pain intensity difference in less time. Moreover, the use of FNB had fewer side effects and more Hemodynamics stability compared to opioids.

Keywords: femur fracture, nerve block, fentanyl, ultrasound guided

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15 Trends, Attitude, and Knowledge about the Methods of Labour Pain Management among Polish Women

Authors: Kinga Zebrowska, Maria Falis, Katarzyna Kosinska-Kaczynska, Bartosz Godek, Olga Plaza, Katarzyna Kwiatkowska

Abstract:

Introduction: According to the ministerial decree of 16 August 2018, each woman in Poland during childbirth has the right to the pharmacological and non-pharmacological labour pain management (LPM). Aim: The aim of the study was to assess the knowledge of Polish mothers about pharmacological and non-pharmacological LPM, to investigate which methods they chose and their satisfaction with chosen ones. Material And Methods: A prospective cross-sectional study was performed among women who gave birth between 2015 and 2018. The self-composed questionnaire was distributed via the Internet in October 2018. Results: 13.727 women participated in the study. 75% have learned about LPM from the Internet. 68% of them did not gain any information on LPM from doctors during their prenatal appointments Safety of the newborn (46%), midwife’s advice (40%) and the chance of the immediate pain relief (39%) were the most important issues while choosing LPM. Respondents used a wide range of non-pharmacological methods, such as the assistance of partner during labour (81%), physical activity (58%), immersion in water (37%), relaxation techniques (15%) and others. 11% of mothers did not use any of the LPM methods. 52% of women declared that they wanted to use the pharmacological anaesthesia, while 49% had it performed (28% epidural, 16% inhaled anaesthesia, 5% parenteral opioids). Pharmacological methods were unavailable due to lack of anaesthesiologist in the maternity ward (41%) or inaccessibility of the chosen methods in the hospital (31%) and too advanced labour (43%). 48% of respondents did not decide to use pharmacological methods, because the pain was bearable (29%), anxiety of child’s health (17%), or belief that the pain is natural and it should not be avoided (16%). 83% of respondents believed that epidural analgesia has no influence on the time needed to gain a full cervix dilatation and 81% of them claimed that serious spinal cord injury is a common side effect of epidural. 51% believed that epidural increases the risk of caesarean section. Conclusions: The knowledge about the methods of LPM is not satisfactory. We should focus on well- maintained education guided by doctors, midwives, and media.

Keywords: childbirth, labour pain management, maternity experiences, obstetrics

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14 Regional Anesthesia: A Vantage Point for Management of Normal Pressure Hydrocephalus

Authors: Kunal K. S., Shwetashri K. R., Keerthan G., Ajinkya R.

Abstract:

Background: Normal pressure hydrocephalus is a condition caused by abnormal accumulation of cerebrospinal fluid (CSF) within the brain resulting in enlarged cerebral ventricles due to a disruption of CSF formation, absorption, or flow. Over the course of time, ventriculoperitoneal shunt under general anesthesia has become a standard of care. Yet only a finite number of centers have started the inclusion of regional anesthesia techniques for the such patient cohort. Stem Case: We report a case of a 75-year-old male with underlying aortic sclerosis and cardiomyopathy who presented with complaints of confusion, forgetfulness, and difficulty in walking. Neuro-imaging studies revealed disproportionally enlarged subarachnoid space hydrocephalus (DESH). The baseline blood pressure was 116/67 mmHg with a heart rate of 106 beats/min and SpO2 of 96% on room air. The patient underwent smooth induction followed by sonographically guided superficial cervical plexus block and transverse abdominis plane block. Intraoperative pain indices were monitored with Analgesia nociceptive index monitor (ANI, MdolorisTM) and surgical plethysmographic index (SPI, GE Healthcare, Helsinki, FinlandTM). These remained stable during the application of the block and the entire surgical duration. No significant hemodynamic response was observed during the tunneling of the skin by the surgeon. The patient underwent a smooth recovery and emergence. Conclusion: Our decision to incorporate peripheral nerve blockade in conjunction with general anesthesia resulted in opioid-sparing anesthesia and decreased post-operative analgesic requirement by the patient. This blockade was successful in suppressing intraoperative stress responses. Our patient recovered adequately and underwent an uncomplicated post-operative stay.

Keywords: desh, NPH, VP shunt, cervical plexus block, transversus abdominis plane block

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13 Distraction from Pain: An fMRI Study on the Role of Age-Related Changes in Executive Functions

Authors: Katharina M. Rischer, Angelika Dierolf, Ana M. Gonzalez-Roldan, Pedro Montoya, Fernand Anton, Marian van der Meulen

Abstract:

Even though age has been associated with increased and prolonged episodes of pain, little is known about potential age-related changes in the ˈtop-downˈ modulation of pain, such as cognitive distraction from pain. The analgesic effects of distraction result from competition for attentional resources in the prefrontal cortex (PFC), a region that is also involved in executive functions. Given that the PFC shows pronounced age-related atrophy, distraction may be less effective in reducing pain in older compared to younger adults. The aim of this study was to investigate the influence of aging on task-related analgesia and the underpinning neural mechanisms, with a focus on the role of executive functions in distraction from pain. In a first session, 64 participants (32 young adults: 26.69 ± 4.14 years; 32 older adults: 68.28 ± 7.00 years) completed a battery of neuropsychological tests. In a second session, participants underwent a pain distraction paradigm, while fMRI images were acquired. In this paradigm, participants completed a low (0-back) and a high (2-back) load condition of a working memory task while receiving either warm or painful thermal stimuli to their lower arm. To control for age-related differences in sensitivity to pain and perceived task difficulty, stimulus intensity, and task speed were individually calibrated. Results indicate that both age groups showed significantly reduced activity in a network of regions involved in pain processing when completing the high load distraction task; however, young adults showed a larger neural distraction effect in different parts of the insula and the thalamus. Moreover, better executive functions, in particular inhibitory control abilities, were associated with a larger behavioral and neural distraction effect. These findings clearly demonstrate that top-down control of pain is affected in older age, and could explain the higher vulnerability for older adults to develop chronic pain. Moreover, our findings suggest that the assessment of executive functions may be a useful tool for predicting the efficacy of cognitive pain modulation strategies in older adults.

Keywords: executive functions, cognitive pain modulation, fMRI, PFC

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12 Comparison of the Efficacy of Ketamine-Propofol versus Thiopental Sodium-Fentanyl in Procedural Sedation in the Emergency Department: A Randomized Double-Blind Clinical Trial

Authors: Maryam Bahreini, Mostafa Talebi Garekani, Fatemeh Rasooli, Atefeh Abdollahi

Abstract:

Introduction: Procedural sedation and analgesia have been desirable to handle painful procedures. The trend to find the agent with more efficacy and less complications is still controversial; thus, many sedative regimens have been studied. This study tried to assess the effectiveness and adverse effects of thiopental sodium-fentanyl with the known medication, ketamine-propofol for procedural sedation in the emergency department. Methods: Consenting patients were enrolled in this randomized double-blind trial to receive either 1:1 ketamine-propofol (KP) or thiopental-fentanyl (TF) 1:1 mg: Mg proportion on a weight-based dosing basis to reach the sedation level of American Society of Anesthesiologist class III/IV. The respiratory and hemodynamic complications, nausea and vomiting, recovery agitation, patient recall and satisfaction, provider satisfaction and recovery time were compared. The study was registered in Iranian randomized Control Trial Registry (Code: IRCT2015111325025N1). Results: 96 adult patients were included and randomized, 47 in the KP group and 49 in the TF group. 2.1% in the KP group and 8.1 % in the TF group experienced transient hypoxia leading to performing 4.2 % versus 8.1 % airway maneuvers for 2 groups, respectively; however, no statistically significant difference was observed between 2 combinations, and there was no report of endotracheal placement or further admission. Patient and physician satisfaction were significantly higher in the KP group. There was no difference in respiratory, gastrointestinal, cardiovascular and psychiatric adverse events, recovery time and patient recall of the procedure between groups. The efficacy and complications were not related to the type of procedure or patients’ smoking or addiction trends. Conclusion: Ketamine-propofol and thiopental-fentanyl combinations were effectively comparable although KP resulted in higher patient and provider satisfaction. It is estimated that thiopental fentanyl combination can be as potent and efficacious as ketofol with relatively similar incidence of adverse events in procedural sedation.

Keywords: adverse effects, conscious sedation, fentanyl, propofol, ketamine, safety, thiopental

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11 Utilizing Literature Review and Shared Decision-Making to Support a Patient Make the Decision: A Case Study of Virtual Reality for Postoperative Pain

Authors: Pei-Ru Yang, Yu-Chen Lin, Jia-Min Wu

Abstract:

Background: A 58-year-old man with a history of osteoporosis and diabetes presented with chronic pain in his left knee due to severe knee joint degeneration. The knee replacement surgery was recommended by the doctor. But the patient suffered from low pain tolerance and wondered if virtual reality could relieve acute postoperative wound pain. Methods: We used the PICO (patient, intervention, comparison, and outcome) approach to generate indexed keywords and searched systematic review articles from 2017 to 2021 on the Cochran Library, PubMed, and Clinical Key databases. Results: The initial literature results included 38 articles, including 12 Cochrane library articles and 26 PubMed articles. One article was selected for further analysis after removing duplicates and off-topic articles. The eight trials included in this article were published between 2013 and 2019 and recruited a total of 723 participants. The studies, conducted in India, Lebanon, Iran, South Korea, Spain, and China, included adults who underwent hemorrhoidectomy, dental surgery, craniotomy or spine surgery, episiotomy repair, and knee surgery, with a mean age (24.1 ± 4.1 to 73.3 ± 6.5). Virtual reality is an emerging non-drug postoperative analgesia method. The findings showed that pain control was reduced by a mean of 1.48 points (95% CI: -2.02 to -0.95, p-value < 0.0001) in minor surgery and 0.32 points in major surgery (95% CI: -0.53 to -0.11, p-value < 0.03), and the overall postoperative satisfaction has improved. Discussion: Postoperative pain is a common clinical problem in surgical patients. Research has confirmed that virtual reality can create an immersive interactive environment, communicate with patients, and effectively relieve postoperative pain. However, virtual reality requires the purchase of hardware and software and other related computer equipment, and its high cost is a disadvantage. We selected the best literature based on clinical questions to answer the patient's question and used share decision making (SDM) to help the patient make decisions based on the clinical situation after knee replacement surgery to improve the quality of patient-centered care.

Keywords: knee replacement surgery, postoperative pain, share decision making, virtual reality

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10 Use of a Novel Intermittent Compression Shoe in Reducing Lower Limb Venous Stasis

Authors: Hansraj Riteesh Bookun, Cassandra Monique Hidajat

Abstract:

This pilot study investigated the efficacy of a newly designed shoe which will act as an intermittent pneumatic compression device to augment venous flow in the lower limb. The aim was to assess the degree with which a wearable intermittent compression device can increase the venous flow in the popliteal vein. Background: Deep venous thrombosis and chronic venous insufficiency are relatively common problems with significant morbidity and mortality. While mechanical and chemical thromboprophylaxis measures are in place in hospital environments (in the form of TED stockings, intermittent pneumatic compression devices, analgesia, antiplatelet and anticoagulant agents), there are limited options in a community setting. Additionally, many individuals are poorly tolerant of graduated compression stockings due to the difficulty in putting them on, their constant tightness and increased associated discomfort in warm weather. These factors may hinder the management of their chronic venous insufficiency. Method: The device is lightweight, easy to wear and comfortable, with a self-contained power source. It features a Bluetooth transmitter and can be controlled with a smartphone. It is externally almost indistinguishable from a normal shoe. During activation, two bladders are inflated -one overlying the metatarsal heads and the second at the pedal arch. The resulting cyclical increase in pressure squeezes blood into the deep venous system. This will decrease periods of stasis and potentially reduce the risk of deep venous thrombosis. The shoe was fitted to 2 healthy participants and the peak systolic velocity of flow in the popliteal vein was measured during and prior to intermittent compression phases. Assessments of total flow volume were also performed. All haemodynamic assessments were performed with ultrasound by a licensed sonographer. Results: Mean peak systolic velocity of 3.5 cm/s with standard deviation of 1.3 cm/s were obtained. There was a three fold increase in mean peak systolic velocity and five fold increase in total flow volume. Conclusion: The device augments venous flow in the leg significantly. This may contribute to lowered thromboembolic risk during periods of prolonged travel or immobility. This device may also serve as an adjunct in the treatment of chronic venous insufficiency. The study will be replicated on a larger scale in a multi—centre trial.

Keywords: venous, intermittent compression, shoe, wearable device

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