Opioid-free anesthesia has become a purposeful alternative to addressing nociception in the perioperative settings. Increased opioid availability has been accompanied by an opioid crisis. Around 1.6 million Americans had an opioid dependence problem in 2019 with 70,000 people dying from overdose every year. The concept of multimodal anesthesia aims to avoid the negative effect of opioid use intraoperatively on the patient's postoperative outcomes. Though adverse sequelae such as ileus, respiratory depression, somnolence, immunosuppression and hyperalgesia are well documented in the literature, the use of diverted prescription opioids can result in addiction or fatal overdose. In recent years concerned researchers and physicians tried to identify practical strategies to a more cautious opioid use and even an opioid free approach. A multidisciplinary perioperative care plan that includes a preoperative evaluation, an intraoperative and postoperative care strategy needs to be formulated. In this case report, we describe pertinent considerations in tailoring a successful opioid sparing analgesia technique that provided superior pain relief using multiple interventions of local anesthetics (MILANA) for a patient undergoing a complex abdominal surgery.
Del Nido cardioplegia is widely used in current pediatric cardiac surgery practice in North America and its application is also being extended to adult cardiac surgical procedures. Here we will review the physiology of del Nido cardioplegia based on our personal discussion with Dr. del Nido and the published literature.
Codeine and tramadol are two commonly used opioids for pediatric pain. However, death and severe respiratory distress cases following codeine administration illustrated there would be a significant heterogenous response to these opioids depending on CYP2D6 phenotypes, leading to FDA warning against pediatric use. Here we will comment on the current status of pediatric pain management in the context of codeine and tramadol.
An expert panel including policy experts, society leaders, anesthesiologists, pain specialist, pharmacologist, a medicinal chemist, basic and clinical scientists, physician entrepreneurs, educators, and leaders from pharmaceutical companies from the United States and China had a round table discussion on the current issues and potential solutions related to perioperative opioid management. The inappropriate usage of opioids in the perioperative period remains an important safety concern for patients, care providers, and the general public across the world. There is a huge difference in usage practice of opioids between China and USA, therefore, to bring experts from both sides could generate new viewpoints or consensus in driving better pain control with safer usage of opioids for patients in different medical systems, which might be applicable to many countries and regions. The following topics were discussed: 1) The policy and its impact on opioid usage and crisis; 2) Education on opioid usage and management; 3) Opioid monitoring and waste management; 4) Novel opioid development; 5) Perioperative opioid usage and outcome. All the panelists agreed that standardized terminology for opioid usage and opioid pharmacology should be developed, and we should work out reasonable and practical recommendations for a safe and effective usage and management for opioids in the perioperative period.
Despite some advances that have been made in the clinical management of sepsis, its morbidity and mortality rates remain high. The pathogenesis of systemic inflammation and organ damage leading to septic mortality is not fully understood. Interleukin-33 (IL-33), a new member of the IL-1 superfamily, can be a traditional cytokine and a nuclear factor regulating gene transcription. Due to its biological characteristics, IL-33 can act as a double-edged sword in sepsis: It not only contributes to clear bacteria and improves survival but also causes inflammation, immunosuppression, and organ damage via modulating immune response. In this review, we will summarize updated information on the dual functions of IL-33 in the host immune response to sepsis.
This editorial discusses the status and issues related to perioperative opioid usage monitoring and waste. Opioid detection of wasted material is briefly discussed also. Flowlytics® from Invistics is a digital system to monitor opioid usage and waste in medical facilities. Opioid waste in medical facilities has a two-person witness procedure. Easy to use detection of wasted materials needs to be developed in the future. It is unclear whether the strategies used in medical facilities should be recommended for opioid disposal in the public to reduce opioid diversion. Relevant studies are needed.
being biliary atresia, toxicities, and metabolic, genetic, and infectious diseases [2][3][4].Identified indications and absolute contraindications for pediatric LT are given in Table 1.Our data shows that 306 patients underwent living donors, and the most common indications for LT are biliary atresia, biliary atresia where a Kasai procedure has failed glycogen store disorders, and genetic disorders.In our center, the mean age of the patients was 5.8, the Pediatric End-Stage Liver Disease (PELD) score was 12.3, they had many comorbidities, and one-year survival was 90.1%.ESLD requiring LT may have multisystem disorders that require significant anesthetic approaches.However, when an LT is indicated for a child to benefit from the transplant, all perioperative specialties related to the patient should discuss the patient's comorbidities and risks and form a consensus in a multidisciplinary approach [4][5][6][7]. Preoperative AssessmentIn pediatric patients with ESLD, symptoms and signs such as coagulopathy, ascites, and varicose veins are typical.However, such characteristic findings can sometimes be overlooked in patients with ESLD due to metabolic diseases or genetic syndromes.Proper anesthesia management in LT requires
Equal Contributionwhich is used to explain the two opposing and mutually destructive forces in nature.The interaction of yin and yang drives the creation and change of all things and phenomena in the universe [2].For this reason, ancient Chinese physicians concluded that "Yin and Yang have their own name, but no form" [3].The Yin-Yang doctrine states that everything in the universe can be divided into two categories: Yin and yang.Yin or yang alone can be divided into yin (sub-1) and yang (sub-1).Any yin (sub-1) or yang (sub-1) can also be divided into yin (sub-2) and yang (sub-2), and the list is endless [4].The division of yin and yang is based on sunlight, and anything that corresponds to the sunward side is yang, and the backward side is yin.In general, anything that is active, external, ascending, warm, bright, functional, hyper-functional, etc. is yang.Conversely, that which is internal, falling, cold, obscure, material, declining in function, etc., belongs to yin.The relationship between yin and yang has the following characteristics: Correlation, universality, relativity, divisibility, interaction, opposition, complementarity, balance and transformation (Figure 1) [5][6][7][8]. The Yin-Yang Theory in Traditional Chinese Medicine (TCM)The theory of yin and yang was introduced into the field of medicine by renowned practitioners of ancient Chinese medicine.This doctrine is commonly used to explain the origin and nature of life, the maintenance of physiological functions, the regression of pathology, and the basic laws for diagnosing and preventing disease [2].The theory of yin and yang is a fundamental and crucial aspect of Traditional Chinese Medicine (TCM).
