Background : The post anesthesia care unit (PACU) is designed to maintain clinical stability and ensure patient comfort. Failure to optimize these goals delays PACU discharge, consumes resources, and impairs patient satisfaction and healthcare perceptions. Virtual reality (VR) distraction therapy may provide an additional modality to reduce pain and audiovisual annoyance. Methods : Patients were randomized to either receive virtual reality therapy (treatment arm) or not (control) in the PACU. Patients completed a survey measuring outcomes at baseline upon entering PACU and upon discharge from PACU. Scoring included pain, unpleasantness, visual analog scale (VAS) score, any fun experienced and time spent thinking about pain before and after the intervention. Results : Baseline scores upon entry to the PACU before group assignment was revealed were not statistically different. Median initial pain and unpleasantness levels were low given the procedures investigated. Environmental unpleasantness perception changed for the better in the VR group, as did time thinking about fun. The other groups did not provide reliable evidence of change. Conclusion : Virtual reality distraction therapy improves patient satisfaction in the PACU. Further exploration into other perioperative sites may show similar changes in satisfaction and potentially decreased pain.
Introduction: Most of postoperative patients report moderate to severe pain, possibly related to opioid underdosing or overdosing during surgery. Nociception Level (NOL) Index has been proposed for the evaluation of the nociceptionantinociception balance in the perioperative period and by that, may lead to a more appropriate analgesic regimen. NOL-index is scaled from 0 to 100; with previous studies suggesting that values >25 can indicate inadequate analgesia. We designed a NOL-guided and Observational study, 2-cohort (retrospective and prospective) trial to test the hypothesis that protocol-driven intraoperative analgesia guided by NOL during laparoscopic colorectal surgery would improve and reduce titration of intraoperative analgesics. Method: This monocentric, observational, and guided study aimed to compare perioperative data during laparoscopic colorectal surgery with or without the use of NOL monitor (NOL-guided vs. Control group). Intraoperative analgesia was provided by injection of fentanyl, which was performed according to the clinician’s assessment in the Control group or to the NOL monitor in the NOL-guided group. The primary outcome was a reduction in fentanyl consumption during surgery in the NOL-guided group. Results: Between 2017 and 2019, 70 patients (i.e., 36 in the Control group and 34 patients in the NOL-guided group) were included. The mean consumption fentanyl was significantly lower in the NOL-guided group (450mg) versus 600mg in the Control group (P = 0.005). Median postoperative pain score in T0, when the patient woke up in the operation room, was2 (inter-quartile range 0-5) and 0 (0-4) in Control and NOL-guided group, respectively (p=0.132). Conclusion: The NOL index in laparoscopic colorectal surgery decreased with incremental fentanyl doses during sevoflurane anaesthesia. This reduction in the intraoperative analgesia suggests its interesting potential as a nociception monitor during general anaesthesia (GA). Future studies should employ more robust design, be appropriately powered and seek to follow longer term outcomes.
Coronavirus disease 2019 (COVID-19) has been associated with the rare, yet potentially fatal, condition known as epiglottitis. Epiglottitis has the potential to lead to complete airway obstruction, and often constitutes emergent management. Here, we describe a case of acute epiglottitis in a 19-year-old man infected with COVID-19 with a past history of angioedema.
The hanging-drop method whereby a drop of saline hanging in the hub of an epidural needle is aspirated when the needle entered the epidural space. The theory behind this maneuver has been controversial. Recently I reported this phenomenon might be explained by the release of compressed air inside of the epidural needle into the epidural space [1]. The reason why I reached this theory is that a drop of saline placed within the hub of an epidural needle is sucked in when the needle is advanced and penetrates through a polyurethane foam cube. And I also showed the pressure inside of the epidural needle increased according to the distance the needle traveled to penetrate the polyurethane foam. Furthermore, once we stop advancing the needle, the pressure inside of the needle drops to zero. This may be explained by the leakage of the air inside of the needle. This means the amount of “aspiration” of saline drop differs according to the distance of the needle tip reaches the epidural space through the ligament after advancing the needle. In this way, knowing that the degree of attraction of the saline droplet may change depending
The practice of pain medicine today is faced with the ever-rising burden of the nation's opioid epidemic. There has been a strong push to redefine chronic pain treatments and to find analgesic alternatives that avoid the harmful risks of opioid use that lead to diversion, overdose and addiction. Cannabis has been suggested to be an efficacious and safer alternative or replacement for opioids, but a large gap remains between the reported opioid-sparing benefits of cannabis and scientific evidence from high-quality research.
The purpose of this study was to examine cuff inflation techniques and corresponding pressure estimations, as well as associated complications, in patients undergoing general anaesthesia with intubation for cesarean delivery at the Tamale Teaching Hospital's obstetric unit.
COVID-19 was declared a global pandemic by the WHO in March of 2020. When the COVID-19 pandemic first started, much attention was focused on the respiratory manifestations of the disease. However, as the course of the pandemic continued, more and more attention has been paid to the neurological symptoms after infection with the SARS-CoV-2 virus.
Abstract Purpose: Although epidural analgesia (EA) is recommended for laparotomic (LT) rectal surgery, there is no consensus regarding pain management in laparoscopic or robotic (LR) rectal cancer surgery. According to our local guidelines, EA is usually chosen for LT rectal procedures and intravenous analgesia for LR rectal procedures. Methods: This retrospective study included patients who underwent rectal cancer surgery in our center from January 2016 to February 2020 using either laparotomy (LT) or laparoscopic or robotic (LR) techniques. Analgesia technique varied according to surgery technique, the choice of patient and anesthesia provider. Data were acquired from electronic databases and consisted of pain scores in the recovery room and the three postoperative days, morphine consumption and total length of hospital stay. Results: 151 patients were included: 92 in the LR group and 59 in the LT group. Epidural analgesia was used for 8/92 LR patients and of 48/59 LT patients. Pain scores were comparable regardless of the surgical and analgesic technique in the three postoperative days, but patients with epidural analgesia used significantly less morphine, even in the LR group. After correction for multiple pairwise comparisons, our results showed that in laparoscopic rectal surgery, the use of epidural analgesia was associated with significantly lower morphine consumption (corrected p =0.01, reduction over 3 days: 25 mg). Conclusion: Compared to other analgesia regimens, perioperative epidural analgesia for LR rectal surgery was associated with significantly less postoperative morphine consumption to achieve the same pain scores. EA appears to be beneficial even in laparoscopic rectal surgery.
Background: Interscalene brachial plexus blocks are commonly used to provide adjunctive, non-opioid pain relief as part of a multimodal pain control regimen for shoulder arthroscopy and arthroplasty. The purpose of this study was to assess the clinical efficacy of liposomal bupivacaine compared with a standard bupivacaine plus dexamethasone mixture in a single shot interscalene nerve block for postoperative pain control. Methods: This single-blinded, randomized study was performed after institutional review board approval. Patients were > 18-years-old who underwent shoulder arthroplasty or arthroscopy, and were randomized into 2 groups, those who received an interscalene nerve block with liposomal bupivacaine (LB group) and those who received standard bupivacaine with dexamethasone (SB group). Primary outcomes were numerically graded pain scores (1-10), time to use of any postoperative pain medication, time to use of first postoperative opioid, and milligram morphine equivalents (MME) used up to 72 hours after the nerve block. Results: Forty subjects were included in each group. There was no difference in time to first pain medication of any kind between groups. However, the LB group went a significantly longer time to first opioid than the SB group. Numeric pain scores were statistically lower in the LB group on average and at individual time points but did not reach clinical significance (as defined in previous studies). Cumulative MME up to 24, up to 48 and up to 72 hours were significantly reduced in the LB group. Lastly, a lower dose of bupivacaine (in mg) was needed to achieve a longer duration of block in the LB group. No significant adverse events were reported. Conclusion: Although reductions in pain scores were statistically significant, they did not meet predefined goals for clinical significance. However, interscalene nerve block with LB provided a statistically significant reduction in postoperative opioid use compared with SB + dexamethasone. With improved patient satisfaction, reduced total dose of local anesthetic and reduced reliance on postoperative opioids, our evidence supports value added by use of LB.
In presenting their results comparing the use of sufentanil alone (Group S) versus sufentanil with the addition of remifentanil (Group R) we would like to point out a significant source of potential bias in their study design and reporting of results. Specifically, the authors note that in their protocol atropine was administered in the event of bradycardia and dopamine was administered for hypotension.
Objectives: During the COVID-19 pandemic, many outpatient clinics temporarily closed. Telemedicine appointments, which refer to the remote delivery of healthcare services through audio or visual means, were offered as an alternative to in-person visits in an effort to continue delivering quality patient care while practicing social distancing recommendations in a safe manner. We hypothesize that patient satisfaction with telemedicine visits is similar when compared to in-person office visits during the COVID-19 pandemic. Methods: A retrospective, single institution analysis was conducted to assess patient satisfaction with telemedicine and in-person visits with a chronic pain provider during the COVID-19 pandemic. A total of 170 patient visits were included in the study, including 42 telemedicine and 128 in-person patient visits. Results: Both telemedicine and in-person patients rated the provider similarly on a scale of 0-10, with means of 9.0 and 9.2 respectively [p = 0.56]. A majority of patients in each group, 83.3% for telemedicine and 87.5% for in-person, expressed a high degree of confidence that the care provider knew their medical history [p = 0.6]. Similarly, 83.3 % of telemedicine and 93.0% of in-person expressed a high degree of confidence that the provider listened to them [p = 0.07]. Lastly, 83.3% of telemedicine and 93.0% in-person patients would “definitely recommend” the provider’s office to family and friends [p = 0.07] (Table 1). Discussion: The post appointment surveys were not statistically different between the two studied populations. This supports the notion that telemedicine appointments are potentially non-inferior to in-person appointments in regard to patient satisfaction and provider rating.
Post-craniotomy pain is predominantly superficial, sug gesting somatic origin [8] originating from the scalp, muscles, and soft tissue, with subsequent activation of the pain path way from manipulation of the dura mater [9] . Post-cranioto my pain is usually localized to the surgical site and surround ing structures and results from incision and traction during surgery [10] . The nature of post-craniotomy pain is described Abstract Background: There is increasing evidence supporting increased pain intensity following neurosurgical procedures. There are different approaches to analgesia following craniotomy and cranioplasty, but there is limited consensus on postcraniotomy pain management especially in the pediatric population. Methods: A comprehensive online search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Literature was taken from PubMed, EMBASE, Science Direct, ProQuest, and Google Scholar databases. Human comparative studies including randomized controlled trials and cohort studies evaluating pain scores after neurosurgery in pediatric patients were included in the review. Results: A total of 3 RCTs and 6 cohort studies met the inclusion criteria. The heterogeneity of the studies included did not allow for data pooling and statistical analysis. All studies evaluated the efficacy of pharmacologic interventions in pediatric patients who underwent craniotomy by measuring postoperative pain scores. Continuous opioid infusions postoperatively provided favorable postoperative pain control in pediatric patients without serious opioid-induced adverse complications. Intraoperative doses of opioids for preemptive analgesia had favorable outcomes but still lack evidence. Non-opioid analgesics are suitable adjuncts to postoperative opioids to enhance analgesia and minimize adverse events use of local anesthetics as local scalp infiltration or nerve block for children resulted in lower postoperative pain scores and longer time to first rescue analgesia compared to placebo, but still need further studies. Conclusion: Opioids remain as mainstay treatment for children who underwent neurosurgery but specific recommendation on the method and timing of delivery of opioids cannot be drawn from this review. The use of non-opioid analgesics and local anesthetics for local infiltration and nerve block need further research. There is a lack of high-quality evidence on this field, and additional research is necessary to improve pain management after craniotomy in the pediatric population.
Esophagectomy surgery remains high risk with 36% of patients in the UK having a complication. Tracheostomy insertion can aid weaning from ventilation post-operatively and can be inserted at the time of surgery (elective) or post-operatively (delayed). We aimed to identify factors associated with elective and delayed tracheostomies, as well as differences in outcomes in each group.
Pseudoaddiction is a term to describe drug-seeking behaviors in a patient that has inadequate pain control. It is the result of the medical undertreatment of pain, which poses iatrogenic harm to patients by withholding analgesic treatment [1]. The case presented is of a 26-year-old female with chronic back pain from a motor vehicle accident who was unable to find a physician to prescribe opioids after leaving the care of her primary care physician. She resulted to drug-seeking behaviors and alcohol use to relieve her severe pain.
A 65-year-old male (90 kg and 178 cm) presented for transurethral resection of bladder tumor surgery. The patient had no history of diabetes mellitus, hyperlipidemia, coronary artery disease, or lung disease. He smoked 10 cigarettes a day for 20 years and had managed to abstinence from smoking for the last 25 years. His physical examination revealed a blood pressure of 130/75 mm Hg, a regular pulse of 76 beats/min, and oxygen saturation of 96%.
Interscalene blockade results in a significantly higher incidence of phrenic nerve dysfunction when compared to effects from a supraclavicular approach nerve block. In addition, using local anesthetic volumes more than 20 ml resulted in a higher incidence of phrenic nerve dysfunction, regardless of approach to the brachial plexus when compared to using volumes of 20 ml or less. There were no differences in brachial plexus blockade efficacy or duration of effect between the 2 approaches and using greater or less than20ml volumes of local anesthetic.
Medication errorsare still one of the contributing factors leading to morbidity and mortality in anesthesia, despite measures to ensure patient safety. A 14-year-old male inadvertently received intrathecal tranexamic acid instead of hyperbaric bupivacaine for an elective herniorrhaphy. Shortly after induction, patient complained of severe back and lower limb pain, restlessness, tachycardia, hypertension, and generalized myoclonic seizures.
In 1860, Albert Niemann isolated cocaine from leaves and reported that by placing the crystals on his tongue, and his tongue became benumb. In the Brazil is a country with greatest annual consumption rates becoming one of the biggest consumer markets of cocaine worldwide. The objective of this study, carried out through a questionnaire survey, was to find out the degree of knowledge of anesthesiologists from a tertiary hospital in their conduct towards a cocaine user.
