Challenges and Opportunities in Pain Management

Special Issue:

Challenges and Opportunities in Pain Management

Claudia Cervera Martinez
Neurosurgery Department, National Institute of Neurology and Neurosurgery, Mexico

Fernando J. Zermeño-Pohls
Neurology Department, National Institute of Neurology and Neurosurgery, Mexico

Erik Burgos- Sosa
Neurosurgery Department, National Institute of Neurology and Neurosurgery, Mexico

J. Ramon Martínez-Pablos
Neurosurgery Department, National Institute of Neurology and Neurosurgery, Mexico

Manuel Islas-Alvarez
Neurology Department, National Institute of Neurology and Neurosurgery, Mexico

Juan Luis Gomez-Amador
Neurosurgery Department, National Institute of Neurology and Neurosurgery, Mexico

Abstract

Introduction: Headache in neurosurgical patients is an important clinical problem that has been receiving an increasing amount of attention. However, only a few studies have described cases of headache following craniotomy, and even fewer have proposed pain management for this pathology. In contrast, general postoperative pain has been extensively studied, and there are thus many guidelines to treat such pain. Here we propose a regimen that includes the use of analgesics based on postoperative pain guidelines.

Material and Methods: A randomized prospective study was performed on all neurosurgical patients who had underwent craniotomy at the National Institute of Neurology and Neurosurgery between September 2016 and September 2017. The subjects were subdivided into control and experimental groups. Each group comprised 50 patients. Analgesic management in the experimental group was based on multimodal analgesia.

Results and Discussion: There was a significant difference in the Analogue Visual Scale scores between the control and experimental groups, both on the last hospitalization day (p = 0.000) and at the 6-month follow-up (p = 0.002). There was thus a significant amelioration of pain among patients in the experimental group when compared to those in the control group.

Adequate preoperative and follow up pain management is of most importance for patient care and outcome.Our findings indicate that there was a decrease in pain following multimodal analgesia in post-craniotomy patients

Conclusion: Based on the results obtained in this study and the previously reported evidence, we suggest that postoperative management of acute and persistent headache in patients who undergo craniotomy should comprise multimodal analgesia.

Richard A Lawhern, PhD

Abstract

This paper addresses the question, “Are clinicians who treat patients in pain – or even specialists in addiction medicine — appropriately prepared to accurately diagnose opioid use disorder? Further, is prevailing public policy on pain management employing opioid analgesics firmly grounded in science?” The author summarizes key findings from reviews of pertinent medical literature on pain treatment and diagnosis of substance use disorder.

Medical doctors are widely understood to be inadequately trained in diagnosis of both pain and addiction among their patients.

There is currently no consensus standard of practice to guide clinicians in either prescription of opioids or diagnosis of “substance use disorder” among patients treated for pain.  Available medical literature and clinical experience do not support the thesis that clinicians prescribing in a continuing relationship with pain patients have contributed measurably to the widely discussed US “opioid crisis”

General principles on the management of pain and the diagnosis of substance use disorder do exist but are not widely understood by practicing clinicians. Entry of a “substance use disorder” or “addiction” code in patient electronic medical records can be a literal “kiss of death” for ongoing treatment of severe pain. Thus it seems necessary to caution clinicians who treat pain – and policy makers who oversee them – that much of what they think they “know” about substance use disorder and its causes may no longer be current or may have been wrong in the first place.

Taylor Raffa, MD
The George Washington University Hospital, Department of Surgery, Washington, DC.

Parker Chang, BS
The George Washington University School of Medicine and Health Sciences, Department of Surgery, Washington, DC.

Babak Sarani, MD, FACS, FCCM
The George Washington University Hospital, Department of Surgery, Washington, DC.; The George Washington University School of Medicine and Health Sciences, Department of Surgery, Washington, DC.

Susan Kartiko, MD, PhD, FACS
The George Washington University Hospital, Department of Surgery, Washington, DC.; The George Washington University School of Medicine and Health Sciences, Department of Surgery, Washington, DC.

Abstract

Rib Fractures are a common injury in trauma patients and affect 10% of all injured patients who require admission to the hospital. Currently, there is no consensus on the most efficacious treatment for rib fractures with the debate comparing non-surgical versus surgical management. Medical management of rib fractures often requires admission to the intensive care unit with a focus on pain control to allow good pulmonary hygiene. Pain control involved a multimodal approach with current techniques including epidural anesthesia and paravertebral blocks. Although many patients recover with medical management alone, some patients may benefit from surgical stabilization of rib fractures as a means of augmenting pain control. Flail chest is the most evidence-based indication for surgical stabilization of rib fractures SSRF with many studies showing decreased days on mechanical ventilation, risk of pneumonia, intensive care unit length of stay, and hospital length of stay. Additionally, in patients with non-flail chest and ventilator dependent respiratory failure, surgical stabilization of rib fractures may provide an advantage over medical management for pain control. There are relatively few contraindications and complications associated with surgical stabilization of rib fractures. Therefore, with proper patient selection, surgical stabilization of rib fractures can improve outcomes in patients with rib fractures. Medical management with or without surgical intervention requires a multidisciplinary approach to prevent adverse clinical outcomes.
Richard A Lawhern, PhD
 

Abstract

The US regulatory climate pertaining to the prescribing of opioids in acute and chronic pain is presently highly fraught and polarized. The US Center for Disease Control has claimed that over-prescription of opioids by clinicians to their patients is an ongoing major cause of narcotics addiction and overdose mortality. Despite this premise having been conclusively disproved, many US clinicians face disciplinary proceedings and sanctions by State Medical Boards or the US Drug Enforcement Administration (DEA). Those who have not left pain medicine altogether are under pressure to force-taper legacy patients below arbitrary and scientifically unsupported dose thresholds. Patients are being deserted to agony and medical collapse. Clinicians are being imprisoned for no crime other than treating their patients with safe and effective opioid therapy.

This paper offers a compendium of 81 references for clinicians practicing in pain medicine and for their lawyers, who choose to contest undeserved persecution or legal sanctions by State Medical Boards or the US DEA. Also of interest are recent references that demonstrate beyond any reasonable contradiction that the incidence of iatrogenic addiction to prescription opioids is so low that it cannot be reliably measured. The DEA has known for at least three years that the US opioid “crisis” was not created and is not being driven by clinicians “over-prescribing” to patients.

Among references provided herein are papers demonstrating that the US DEA has been aware for years that over-prescribing of opioid pain relievers is not a dominant cause of either hospital admissions or mortalities involving clinically prescribed opioid analgesics. This awareness may offer grounds for appeal or vacation of court verdicts finding clinicians in violation of “usual and normal” practice of pain medicine.

METHODOLOGY

This paper comprises a critical review and analysis of medical literature pertinent to safety and effectiveness of prescription opioid analgesics employed by clinicians in the management of acute or chronic pain. Taken in combination, the references herein challenge prevailing memes and misdirection in regulation of prescription pain relievers and in otherwise unfounded prosecutions of clinicians by the US Drug Enforcement Administration, State drug enforcement authorities, and State Medical Boards.

The assembled references are selected by the author from over 15,000 accumulated papers and articles acquired during 26 years of reading clinical and popular literature as a data analyst, healthcare writer and patient advocate. Clearly, the author operates from a personal agenda of advocacy on behalf of clinicians and their patients. Evaluation of the scientific and conceptual validity of the references must ultimately rest with Medical Boards and courts in an essentially adversarial process.

Pallavi Agarwal, MD

James J Burns, MD, MPH

Erlyn Smith, MD

Abstract

Introduction: National Heart, Lung, and Blood Institute recommends giving the first dose of opioids within 30 minutes of presentation to the emergency department for sickle cell disease patients with moderate to severe vaso-occlusive crisis. Intranasal fentanyl has been used extensively and shown to reduce time to the first dose of analgesic, improve pain scores at 20 minutes, and increase the odds of getting discharged from the emergency department.

Material and methodsFor phase one of the project, baseline data was collected. The new pain algorithm was introduced at the start of the second phase, which involved giving intranasal fentanyl as the first analgesic for vaso-occlusive crisis in the emergency department. After the intervention, the second analysis compared outcomes with phase one. Wilcoxon-Mann-Whitney tests were used for comparing data between phase one and phase two and Wilcoxon signed-rank tests (paired version) were used for comparing pain scores before and after analgesic.

Results: Visits at phase two had significantly lower hospitalization rate [phase one 53.5% vs. phase two 34.2%(p value 0.005)], more fentanyl use [phase one 1.5% vs. phase two 50.6% (p< 0.001)], less patient-controlled-analgesia (PCA) opioid use after admission [phase one 13.0% vs. phase two 2.53% (p= 0.016)], higher compliance with outpatient visits [phase one 61.3% vs. phase two 98.7% (p < 0.001)], shorter length of hospital stay [phase one 117.6 ± 112.7 hours vs. phase two 68.3 ± 47.2 hours (p-value 0.01)], decrease in the time to first analgesic after coming to the emergency department (phase one 78.2 ± 131.2 minutes vs. phase two 38.3 ± 31.2 minutes (p 0.85)], and decrease in the mean pain score after first medication in the emergency department [phase one 5.48 ± 3.12 vs. phase two 4.46 ± 2.88 (p value 0.021)]

Conclusion: Intranasal fentanyl led to more effective and timely management of vaso-occlusive crisis with improvement in clinical outcomes compared to standard management.

Vako Ilda
Healthcare Management, Hellenic Open University, Greece; Evaggelismos General Hospital, Greece.

Eirini Patsaki
Department of Physiotherapy, University of West Attica, Greece

Alexandros Kouvarakos
Evaggelismos General Hospital, Greece

Vaios Grammatis
Healthcare Management, Hellenic Open University, Greece

Ioannis Kouroutzis
Healthcare Management, Hellenic Open University, Greece; Nursing Department, University of Thessaly, Greece

Theodora Paisia Apostolidi
Medicine University of Sofia, Bulgaria

Vasiliki Roka
Healthcare Management, Hellenic Open University, Greece

Anastasia Kotanidou
Evaggelismos General Hospital, Greece

Pavlos Sarafis
Healthcare Management, Hellenic Open University, Greece; University of Thessaly, Greece

Maria Malliarou
Healthcare Management, Hellenic Open University, Greece; Nursing Department, University of Thessaly, Greece

Abstract

Healthcare professionals during the pandemic in the Greek public healthcare system have experienced increased psychological distress, fear and a greater intention to quit their jobs. This study analyzes the factors of moral distress and moral resilience of healthcare professionals employed during the second wave of the pandemic. The target group was the healthcare professionals (HP = 169) who served in the Evaggelismos General Hospital Covid-clinics and -ICU for 2022 and data were collected through life protocols.

Healthcare professionals believe that when faced with moral challenges, they are able to discern them and think clearly. They are especially stressed when they care for more patients than they can safely handle when they are involved in care that causes unnecessary suffering or does not adequately relieve pain or symptoms, and when they notice that patient care is getting worse. Also stressful are the situations, leading to the creation of possible moral distress, when they witness a violation of a standard of practice or moral code. Factors that lead or may lead healthcare professionals to moral distress are nursing safety, unnecessary and deteriorating patient care, and violation of medical confidentiality, violation of standards of practice or moral codes.

The score on the MMD-HP scale indicates low-to-moderate levels of moral distress. Based on the RMRS scale the moral resilience of healthcare professionals is characterized by moderate-to-high with the highest scores per statement seen when patient care is getting worse and feel pressured to ignore situations where patients have not been given adequate information. The healthcare professionals report that they have either left or have considered leaving their position in a clinic due to moral distress, although they are not currently thinking of leaving their position. The factors that increase the frequency of moral distress and decrease their moral resilience are feeling powerless anxiety, nursing/treatment errors, aggressive treatment, caring for more patients than they can handle, substandard patient care, and hierarchical teams.

Jae-kook Yoo
Department of Neurology, The Rodem Hospital, Incheon, Korea.

Soon-Hee Kwon
Department of Neurology, The Rodem Hospital, Incheon, Korea.

Jong-Eun Jeon
Department of Neurology, The Rodem Hospital, Incheon, Korea.

Sul-Hee Yoon
Department of Internal Medicine, The Rodem Hospital, Incheon, Korea.

Jung-Eun Lee
Department of Rehabilitation Medicine, The Rodem Hospital, Incheon, Korea.

Sang-Yoon Lee
Department of Rehabilitation Medicine, The Rodem Hospital, Incheon, Korea.

Abstract

This case report from the Rodem Hospital introduces a pioneering intervention for muscle rigidity in Amyotrophic Lateral Sclerosis (ALS), featuring a unique placental extract injection and glucose injection therapy combined with lidocaine. This novel approach has demonstrated significant muscle regeneration and sustained relaxation in 47 ALS patients. Unlike traditional treatments, this protocol offers a more sustainable and regenerative outcome. The treatment involved injections of a mixture containing glucose, lidocaine, and placental extract, targeting severely rigid muscles. Remarkably, 42 of the 47 patients showed considerable improvements in knee flexion and a dramatic reduction in pain. The other two also experienced notable progress. This method stands out for its cost efficiency, impact on muscle suppleness, and reduced pain, suggesting a potential paradigm shift in ALS management. This case series highlights the importance of continued innovation and personalized treatment strategies in ALS care, aiming to improve patient quality of life and functional abilities.

This case report from the Rodem Hospital introduces a pioneering intervention for muscle rigidity in Amyotrophic Lateral Sclerosis (ALS), featuring a unique placental extract injection and glucose injection therapy combined with lidocaine. This novel approach has demonstrated significant muscle regeneration and sustained relaxation in 47 ALS patients. Unlike traditional treatments, this protocol offers a more sustainable and regenerative outcome. The treatment involved injections of a mixture containing glucose, lidocaine, and placental extract, targeting severely rigid muscles. Remarkably, 42 of the 47 patients showed considerable improvements in knee flexion and a dramatic reduction in pain. The other two also experienced notable progress. This method stands out for its cost efficiency, impact on muscle suppleness, and reduced pain, suggesting a potential paradigm shift in ALS management. This case series highlights the importance of continued innovation and personalized treatment strategies in ALS care, aiming to improve patient quality of life and functional abilities.

Jan Kersschot
Private Practice, Pain Management and Sports Injuries, Aartselaar, Belgium.

H Gharaei
Private Practice, Founder of International Sonoguide Pain School, Tehran, Iran.

T Mathieu
Department of ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Department of Physical and Rehabilitative Medicine, AZ Rivierenland, Rumst, Belgium.

J Ferrie
Musculoskeletal Podiatrist – B. Pod. (La Trobe), PG Cert Adv Pharm; Mem. A. Pod. A, CMSK, Melbourne, Australia.

Abstract

Medial tibial stress syndrome, sometimes referred to as shin splints, is an overuse injury of the lower extremities. It is commonly managed conservatively, but there is lack of consensus on the application of new treatment options such as regional dextrose 5% injections in regional superficial fascia. Over the last decade, regional dextrose 5% injections are popular for the treatment of orthopedic complaints and sports injuries because of easy application, low cost and excellent safety profile. This article describes a 25-year-old runner suffering from pain in both shins for several years. His pain level went from 7/10 to 0/10 after three sessions of dextrose 5% injections in the superficial fascia, and he recovered permanently after five sessions. This case report is an invitation to design more studies to confirm whether this novel approach may become one of the new tools for athletes suffering from shin splints.

 

 

Leon Margolin
Comprehensive Pain Management Institute, LLC, Columbus, Ohio, USA

Daniel Margolin
Comprehensive Pain Management Institute, LLC, Columbus, Ohio, USA

Jeremy Luchins
Comprehensive Pain Management Institute, LLC, Columbus, Ohio, USA

Michelle Margolin
Comprehensive Pain Management Institute, LLC, Columbus, Ohio, USA

Sanford Lefkowitz
Comprehensive Pain Management Institute, LLC, Columbus, Ohio, USA

Abstract

Setting and Objective.  With still rising drug overdose deaths already at unprecedented alarming levels, reliable indicators of addiction and addiction-vulnerability are urgently needed.  In the U.S., NARX scores are widely accepted as providing objective measures / predictors of drug-addiction risk.  NARX scores are deemed especially useful when informing a broad patient-profile.  Such profiles may to good advantage be enriched by patients’ answers to standard health questionnaires dealing with drug usage, but the advantage is blunted by questionable candor of patients’ answers.  Use of questionnaires – and, thereby, NARX scores – would be enhanced by questions eliciting more honest answers. 

Design and Participants.  Our research explores the utility of questions relating to food-addictive behaviors as proxies for and/or adjuncts to standard questionnaires.  Our questions’ respondents were 100+ chronic pain patients with well-developed patient-profiles, including up-to-date NARX scores.  The patients responded to the same areas of inquiry found on standard questionnaires directly probing patients’ drug exposure / use / abuse / addiction, but with food categories as selection-choices: Questions regarding what a patient would intake for improvement of mood; in the absence of which, the patient experiences withdrawal; intake of which, diminishes participation in normal activities; etc., were followed by selection-choices of such foods as ‘Chocolate’ and ‘Meat’ in place of selection-choices of drugs – with a total of eight questions, each presenting an identical set of four food selection-choices.  Our questionnaire elicited over 800 question-selection pairs (e.g., mood-Chocolate; mood-Meat; withdrawal-Chocolate; withdrawal-Meat).  Relationships between NARX scores and respondents’ choices were assessed by linear regression and t-distribution analyses. 

Results.  For particular question-selection pairings, the statistical analyses demonstrated strong correlations between risk factors reflected in NARX scores and food-addictive behavioral patterns.  Notably, Meat as the selection for those high-correlation questions was associated with the chronic pain patients with the highest NARX scores (i.e., at highest risk); Cheese, the lowest.  Other foods reported with high frequency were sodas and sweets, underscoring the role of sugar in chronic pain syndromes. 

Conclusions.  Questionnaires probing selected food-addictive behaviors, with higher expectation than drug-related questions of eliciting honest answers, may serve to complement patient-profiles with regard to addiction-vulnerability and, thereby, enhance the use of NARX scores in confronting current rising tides of drug addiction, such as those currently manifested in the growing opioid epidemic.  We note the utility of such food-centric questionnaires in building addiction profiles in demographics that may not have informative NARX scores, such as recent immigrants.  We advocate further clinical studies exploring food-addictive behaviors as proxies for and/or adjuncts to drug-addictive behaviors.

Devika Dua
Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust Coventry, UK

Nicola Gullick
Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK

Catherine Tonks
Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust Coventry, UK

Keir Young
Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust Coventry, UK

Tim Blake
Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust Coventry, UK; Warwick Medical School, University of Warwick, Coventry, UK

Abstract

Introduction: Axial Spondyloarthritis is a complex and heterogenousisorder. The disease varies significantly leading to a diverse spectrum of management choices. We analysed retrospective clinical data from our centre to identify factors associated with multiple biologic switches. We used clustering analysis, an unsupervised machine learning algorithm, and multivariate logistic regression.

Aim: To identify factors associated with a higher frequency of biologic switches in axial spondyloarthropathy patients in a real-world clinical setting.

Materials and Methods: Data were collected retrospectively from the consultations of 166 patients receiving biologic treatment for axial spondyloarthropathy at our centre from 2003 until 2021. Feature selection included: demographics; body mass index; clinical phenotype (axial involvement; peripheral arthritis; enthesitis; uveitis; psoriasis; inflammatory bowel disease); HLA-B27 positivity; radiographic disease; chronic widespread pain diagnosis; disease activity measures (baseline and aggregate scores over disease course) – Bath Ankylosing Spondylitis Disease Activity Index; Spinal pain Visual Analogue Score; Bath Ankylosing Spondylitis Functional Index; C-reactive protein; time to start biologic from diagnosis; number of biologics and mode of action. Clustering analysis included two additional variables: – response to Tumour Necrosis Factor inhibitors and Interleukin-17 inhibitors. Patients were defined as high biologic switchers if they received three or more biologics (not including non-medical switches to biosimilar agents). Multi-variate logistic regression was performed using MNLogit algorithm and clustering analysis using the k-means algorithm (Anaconda Distribution 2.7).

Results: Clustering partitioned our dataset into three clusters: Low Disease Burden (LDB), High Disease Burden 1(HDB1) and High Disease Burden 2(HDB2). The LDB cluster showed good response to treatment, lower disease activity scores and fewer treatment switches. HDB clusters had higher disease activity scores; however, the HDB1 patients had significantly fewer biologic switches. Common features of the HDB1 cluster were female sex, HLA-B27 negativity, less radiographic disease, and more chronic widespread pain diagnosis. Multivariate logistic regression showed that HLA-B27 positivity and higher disease activity scores were positively associated with more biologic switches, whereas time to start biologic and a diagnosis of chronic widespread pain were negatively associated.

Conclusion: HLA-B27 positivity, male sex, higher radiographic burden, higher disease activity scores and early biologic requirement were associated with more biologic switches. Females with axial spondyloarthropathy, HLA-B27 negativity and lower radiographic disease burden had significantly fewer biologic switches despite higher disease activity scores and were more likely to have accompanying chronic widespread pain. Despite advances in treatment, patients with high symptom burden pose a challenge in clinical practice. Consideration should be given to objective and holistic assessment of symptoms and treating other associated conditions, as necessary.

George Trad, MD
Internal Medicine Residency Program, Sunrise Health GME Consortium, Las Vegas, NV

Rasiq Zackria, DO
Gastroenterology and Hepatology Fellowship Program, Sunrise Health GME Consortium, Las Vegas, NV

Syed Abdul Basit, MD
Gastroenterology and Hepatology Fellowship Program, Sunrise Health GME Consortium, Las Vegas, NV; Comprehensive Digestive Institute of Nevada, Las Vegas, NV

John K. Ryan, MD
Gastroenterology and Hepatology Fellowship Program, Sunrise Health GME Consortium, Las Vegas, NV; Comprehensive Digestive Institute of Nevada, Las Vegas, NV

Abstract

Necrotizing pancreatitis (NP) is a life-threatening complication of acute pancreatitis. It requires an extended hospital stay, aggressive management, and has a higher risk of mortality. Risk factors such as comorbidities in the patient’s history including history of coronary artery disease and cerebrovascular disease can increase the risk of developing necrotizing pancreatitis. The presentation of necrotizing pancreatitis is similar to acute pancreatitis, but specific labs such as hematocrit level can be monitored to anticipate the development of necrotizing pancreatitis.  In addition, diagnostic imaging must be obtained to classify necrotizing pancreatitis and aid in management choice. Fluid hydration, adequate pain management, and nutritional support are the principles of treating necrotizing pancreatitis. Deciding whether to drain the necrotic collection or not is usually determined based on the type of necrosis present and whether it is infected.  Infected necrotizing pancreatitis can also occur, and patients usually need to be monitored closely with appropriate antibiotics for a long duration. Patients affected by necrotizing pancreatitis can potentially develop complications that can lead to devastating outcomes. Necrotizing pancreatitis complications can occur due to an inflammatory reaction on the adjacent structure such as splanchnic vein thrombosis, gastrointestinal fistula or inflammatory reaction within the pancreas leading to an exocrine and an endocrine pancreatic insufficiency. We present here a literature review of necrotizing pancreatitis and the complications that can arise from it.

Howard D Palte
Department of Anesthesiology, Perioperative Medicine and Pain Management, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine Miami, FL

Neil H Masters
Department of Anesthesiology, Perioperative Medicine and Pain Management, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine Miami, FL

Abstract

In recent decades there have been few changes in the anesthesia management of eye surgery. By contrast, the 21st Century has witnessed major advancements in ophthalmic surgery with the adoption of minimally-invasive techniques, technologic innovations, and an expanding population seeking eye care. These  factors have impacted intraoperative exposure such that many procedures are now performed on more complex patients, and completed in quicker time. Furthermore, in pursuit of economic savings and patient satisfaction there is a trend to divert eye surgeries away from the in-hospital setting to ambulatory centers or office locations. From an anesthesia perspective, these changes have imposed a demand on providers to shorten operating room turnover times and accelerate patient discharge while maintaining high standards of patient safety. This review will address five new avenues of anesthesia care, each of which offer possibilities in accommodating facets of this new order surgical experience.  First, remimazolam is an ultra-short acting benzodiazepine that produces a predictable period of hypnosis and rapid, full recovery of consciousness because of its short context-sensitive half-time and inactive metabolites. A single 3-5 mg dose produces 11-15 minutes sleep that may be ideal for brief ocular interventions. Second, nasal CPAP/BiPAP and high flow nasal oxygen devices expand the profile of patients appropriately managed at an ambulatory center. Since their application improves arterial oxygenation and delays the onset of apneic hypoxemia, they are advantageous for patients afflicted by morbid obesity or severe obstructive sleep apnea. Third, open globe injuries have traditionally been managed under general anesthesia. However, recent studies attest to regional anesthesia as a viable alternative for many ocular insults, particularly for the elderly and patients with major organ dysfunction or risk for pulmonary aspiration. Fourth, the sub-Tenon block is a cannula-based regional ophthalmic skill performed predeominantly by ophthalmic surgeons because it necessitates conjunctival incision and dissection. Recently described variations of an incision-free, easily mastered sub-Tenon approach are likely to be included in residency and fellowship instruction, and so become an invaluable component of the anesthesiology armamentarium. This review concludes with a concise overview of the a2 agonist dexmedetomidine with the focus directed on its uses as an adjunct for adult sedation, and advantage in children for premedication and control of emergence delirium.

Boubaker Charra
Department of Intensive Care Medicine, Ibn Rochd University Hospital, Faculty of medicine and Pharmacy of Casablanca, Hassan 2 University, Casablanca, Morocco

Yassine Bou-ouhrich
Department of Intensive Care Medicine, Ibn Rochd University Hospital, Faculty of medicine and Pharmacy of Casablanca, Hassan 2 University, Casablanca, Morocco

Abstract

Background: Coronavirus disease of 2019 or COVID-19 is characterised by two main features: the first is the respiratory compromise which corresponds to acute respiratory distress syndrome while the second corresponds to the state of hypercoagulability responsible for thromboembolic complications particularly pulmonary embolism which is the subject of this work. Indeed, a high prevalence of pulmonary embolism has been reported throughout the pandemic period with a significant morbidity and mortality. This reflects the severity of this life-threatening emergency chiefly in the elderly, hemodynamically unstable patients, and patients with severe underlying conditions, mainly cardio-pulmonary comorbidities. The aim of our study is to point out the incidence, the risk factors, the clinical and paraclinical features, the management strategies, and the overall prognosis of pulmonary embolism in critically ill COVID-19 and non-COVID-19 patients.

Patients and methods: It is a retrospective observational study carried out over a two-year-period from January 2019 (non-COVID-19) to December 2020 (COVID-19). Over the study period, 42 cases of COVID-19 and non-COVID-19 pulmonary embolism were collected from an overall set of 611 patients admitted to the medical intensive care unit of the IBN ROCHD university hospital of Casablanca.

Results: The mean age in the COVID-19 group was 64-year-old versus 46-year-old in the non-COVID-19 group. The sex ratio was 1.2 and 0.94 in the non-COVID-19 and COVID-19 group, respectively. Clinical symptomatology was dominated by respiratory failure and chest pain in non-COVID-19 patients while in the COVID-19 group, semiology was dominated by dyspnea, cough, and chest pain. The major sign of severity in both groups was tachypnea.

The chest X-ray was performed in all our patients, it displayed radiological abnormalities in all patients mainly hyper clarity in pulmonary fields. D-dimers were performed in all patients within the two study groups. A chest computed tomography angiogram was performed for all patients and showed unilateral pulmonary embolism in 61% of cases in the non-COVID-19 group versus 61.3% in the COVID-19 group. Cardiac ultrasound was performed for all patients. It showed dilatation of right cavities in both groups (81.8% in non-COVID-19 versus 93.5% in COVID-19 patients). Venous ultrasound of the lower limbs was performed in 96.8% of COVID-19 patients and in 72.7% of non-COVID-19 patients.

With regards to management, all COVID-19 and non-COVID-19 patients received anticoagulation therapy based on standard heparin and anti-vitamin K. Mortality accounted for 54.5% in non-COVID-19 patients versus 74.2% in COVID-19 patients.

Conclusion: COVID-19 pulmonary embolism is often associated with significantly higher morbidity and mortality as compared with non-COVID-19 pulmonary embolism.

 

Jens Rassweiler
Danube Private University Krems

Martin Ringeisen
Department of Orthopedic Surgery and Traumatology, Orthopaedic Medical Center Dr. Ringeisen, Augsburg, Germany.

Karsten Knobloch
Orthopedic Department, SportPraxis Prof. Dr. med. Karsten Knobloch, Hannover, Germany

Wolfgang Schaden
Ludwig Boltzmann Institute for Traumatology, Vienna, Austria

Abstract

Objectives: Wound healing is a complex process that involves inflammation, proliferation, and tissue remodeling to restore damaged tissue integrity. Chronic wounds and ulcers, with incomplete healing and a high risk of recurrence, pose significant challenges to conventional treatments. Extracorporeal Shock Wave Therapy (ESWT) has emerged as a promising wound healing therapy.

Material and Methods: In this review, we summarize the current state of ESWT for wound management based on personal experiences and a comprehensive literature review. Among 184 data sources from 1990 to 2022, 19 relevant publications were identified, including systematic reviews, meta-analyses, and clinical studies applying focused and radial ESWT for various wound types.

Results: ESWT’s mechanism of action involves generating focused or radial shock waves, stimulating tissue repair through angiogenesis, fibroblast proliferation, and collagen expression. Data extracted from systematic reviews showed positive outcomes for wound healing, healing rate, and wound area reduction for chronic wounds such as diabetic foot ulcers, pressure ulcers, and venous ulcers. Studies on radial ESWT revealed similar positive effects in pain reduction and wound healing, with no serious adverse events reported. ESWT exhibited a well-tolerated safety profile, with minor and transient side effects such as reddening, swelling, and mild pain at the treatment site. Comparatively, Hyperbaric Oxygenation Therapy (HBO), an alternative treatment option, showed unique adverse events not observed with ESWT. Our evaluation confirms ESWT as a safe and effective treatment for wound management, offering hope for patients with chronic wounds or ulcers.

Conclusions:  ESWT presents a compelling non-invasive and safe treatment option for various wound healing challenges, improving outcomes for patients with chronic wounds and ulcers. This review highlights the potential of ESWT as an advanced wound healing therapy, complementing conventional approaches. Further studies should explore potential differences between focal and radial ESWT for wound healing.

 

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