Comparison of two techniques (intermittent intravenous bolus morphine vs. morphine infusion) for analgesic titration in patients who had advanced cancer with severe pain: a prospective randomised study

OBJECTIVE

To compare the analgesic efficacy of two techniques of morphine titration (intermittent intravenous bolus vs infusion) by calculating rescue dosage in a day at 1 week after analgesic titration.

METHODS

One hundred and forty cancer patients were randomised into two groups. In group 1, intravenous morphine 1.5 mg bolus given every 10 min until Numerical Rating Scale (NRS) pain score <4 is achieved. Total intravenous dose converted to oral dose (1:1) and administered every 4 hours. In group 2, intravenous bolus morphine 0.05 mg/kg body weight administered followed by 0.025 mg/kg/hour intravenous infusion. The NRS pain score was recorded every 10 min but infusion rate was titrated every 30 min if required. The infusion rate of morphine was doubled if the pain score was unchanged and increased to 50% when NRS was between 4 and baseline. If NRS<4, then infusion at same rate was continued. Once the NRS<4 for two consecutive hours, total intravenous dose for 24 hours was calculated and converted to oral morphine in a ratio of 1:3 and divided into six doses given over 24 hours. For rescue (pain score ≥4) analgesia, one-sixth of the total daily oral dose was prescribed. The primary outcome of this study was to note the number of rescue doses of oral morphine in a day at 1 week.

RESULTS

The rescue dosage in a day at 1-week post discharge from the palliative care unit was significantly higher in group 1 as compared with group 2.

CONCLUSION

Intravenous infusion morphine may be a better analgesic titration technique for analgesia in patients with advanced cancer.

TRIAL REGISTRATION NUMBER

CTRI/2018/04/013369.

Silent Hypoxia in Coronavirus disease-2019: Is it more dangerous? -A retrospective cohort study

BACKGROUND

Hypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterised by the presence of hypoxia without dyspnoea. Silent hypoxia has been shown to affect the outcome in previous studies.

METHODS

This was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory and treatment parameters in patients with silent hypoxia and dyspnoeic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.

RESULTS

Among 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO₂ <94% at the time of presentation. Among them, 174 (21.45%) did not have dyspnoea since the onset of COVID-19 symptoms. Further, 5.2% of patients were completely asymptomatic for COVID-19 and were found to be hypoxic only on pulse oximetry. The case fatality rate in patients with silent hypoxia was 45.4% as compared to 40.03% in dyspnoeic hypoxic patients (P = 0.202). The odds ratio of death was 1.1 (95% CI: 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment and in-hospital complications, which did not reach statistical significance (P = 0.851).

CONCLUSION

Silent hypoxia may be the only presenting feature of COVID-19. As the case fatality rate is comparable between silent and dyspnoeic hypoxia, it should be recognised early and treated as aggressively. Because home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry in the home setting to identify these patients.

To compare clinical versus ultrasound assessment of correct placement of ProSeal Laryngeal mask airway (PLMA): a prospective randomized study

Extraglottic airway devices (EAD) have revolutionized the perioperative airway management. The accuracy of clinical tests to identify malposition has been questioned by recent studies where fibreoptic evaluation identified various malpositions that were undiagnosed by a clinical test. Ultrasound (USG) has evolved to guide various airway interventions. However, USG is under-evaluated in the assessment of the EADs position. Our study aimed to compare clinical versus USG assessment of optimal placement of ProSeal laryngeal mask airway (PLMA). This randomized control trial was done in 212 consenting patients undergoing onco-surgery with PLMA as an airway device. Patients were randomized in Group CL (n-107) and US (n-105). Following primary assessment-using clinical tests and USG evaluation using a scoring system, fibreoptic evaluation of the placement of PLMA was done and then assessed for optimal position. The accuracy of each technique for optimal placement was compared statistically. We found that the sensitivity and specificity of the clinical evaluation were 98.77% and 34.62% with a diagnostic accuracy of 83.18% when compared with fibreoptic evaluation. While USG evaluation using the scoring system has sensitivity and specificity of 95.45% and 29.41% with a diagnostic accuracy of 84.76%. It was noted that USG assessment has a higher positive predictive value (87.5%) as compared to clinical assessment (82.47%). The incidence of rotation was higher in the clinical group. There was no difference in airway related morbidity. USG is comparable to clinical tests for evaluation of the optimal placement of PLMA. However, USG has various advantages over clinical assessment as it is quick and identifies the unacceptable placement of PLMA where the tip of PLMA may not lie over the tip of the esophagus, thereby, avoiding unnecessary mucosal injury during forceful or repeated attempts for gastric drainage tube insertion.Trial registration: Clinical Trials Registry (CTRI/2017/11/010359) dated 3rd November 2017.

Dissemination of Cardiopulmonary Resuscitation Training for Nurses Treating Coronavirus Disease-2019 Patients: A Single-arm Pre-experimental Study

INTRODUCTION

Providing cardiopulmonary resuscitation (CPR) to a coronavirus disease-2019 (COVID-19) patient is challenging for the healthcare providers (HCP). COVID-19 cases have specific CPR requirements, which differ from standard resuscitation efforts.

OBJECTIVE

This paper aims to evaluate whether online learning can be an effective methodology for imparting information on the management of cardiopulmonary arrest in COVID-19 patients due to a novel virus unknown to HCP based on evaluation of knowledge acquisition and satisfaction of the nurses in the new area of medicine and virology.

METHODOLOGY

In a single-arm, one group before and after design, from a cohort of 160 nurses trained in comprehensive cardiac life support (CCLS) formulated by the Indian Resuscitation Council (IRC), 73 nurses participated in the study. After obtaining informed consent through the email from the nurses, baseline data including demographic profile and knowledge related to CPR in COVID-19 patients were collected. An online intervention spread over 1 week was given using a validated e-learning module. The online intervention was found to be effective (pre- and post-intervention knowledge score 13.65 ± 3.01 vs 19.92 ± 1.94, p = 0.001). The majority of nurses were highly satisfied with the content and the training methodology (37.23 ± 4.70).

CONCLUSION

A well-structured, online study material can be used in imparting knowledge and demonstrating the basic and essential skills to nurses, required for giving CPR to COVID-19 patients.

HOW TO CITE THIS ARTICLE

Joshi P, Das S, Thomas M, Mawar S, Garg R, Shariff A, et al. Dissemination of Cardiopulmonary Resuscitation Training for Nurses Treating Coronavirus Disease-2019 Patients: A Single-arm Pre-experimental Study. Indian J Crit Care Med 2022;26(3):327-330.

Comparison between C-MAC and King Vision video laryngoscope (channelled blade) for tracheal intubation in aerosol-prevention intubation box for COVID-19 patients: A manikin-based study

BACKGROUND AND AIMS

The risk of contracting infection while intubating a coronavirus disease 2019 (COVID-19)-positive patient can be reduced by the use of personal protective equipment (PPE), video laryngoscope (VL) and aerosol-preventing intubation box. We compared two VLs (C-MAC and King Vision laryngoscope [KVL]) for ease of intubation and time taken to intubate the manikin using an intubation box.

METHODS

This randomised study involved healthcare workers having experience in using both C-MAC and KVL. After explaining the study and five practice sessions, a total of 63 volunteers were included; 61 participants gave consent and were enroled. The participants were allowed to intubate initially with one VL as per random sequence. Each participant performed three tracheal intubations with each device (C-MAC VL and KVL) on a manikin using an aerosol-prevention box over the head end at the time of intubation.

RESULTS

Time taken, percentage of glottic opening (POGO) score and the number of attempts taken for successful intubation with C-MAC and KVL were comparable in any of the three attempts (P > 0.05). The participants reported more difficulty in using KVL compared to C-MAC, and insertion of laryngoscope blade into the mouth of manikin for intubation was easy in group C-MAC compared to KVL in all three intubations (P < 0.01).

CONCLUSION

C-MAC and KVL take comparable time for successful intubation under COVID-19 simulation conditions. But C-MAC is more user-friendly.

The COVID-19 pandemic: a new epoch and fresh challenges for cancer patients and caregivers-a descriptive cross-sectional study

PURPOSE

Cancer patients and their caregivers are overwhelmed with features of uncertainty, fear, shock, worry, anxiety, sadness, and grief. To add on to their misery, the COVID-19 pandemic has severely afflicted the cancer care delivery. The study was conducted to observe the challenges faced by cancer patients and their caregivers and to formulate strategies for oncological setups to overcome those challenges.

METHODS

After obtaining institutional ethical clearance, a descriptive cross-sectional study was conducted to observe the challenges faced by patients and their caregivers at the level of various domains (physical, logistic, psychological, socioeconomic, and spiritual) who visited the outpatient and inpatient department of cancer pain and palliative care unit. The results were expressed in absolute numbers.

RESULTS

Major challenges encountered were suffering from physical symptoms like pain, nausea, vomiting, dyspnea (90%), postponement of cancer treatment (80%), fear of contracting COVID infection due to hospital visit (93.5%), lack of accommodation (70%), and lack of spiritual clarity and hope (50%).

CONCLUSIONS

Major challenges faced by patients were in physical and psychological domains, and those by caregivers were in socioeconomic domains and handling physical symptoms of their patients. It is imperative to recognize and be cognizant of the challenges faced by cancer patients and their caregivers. Health care setups should formulate strategies to alleviate these challenges and provide holistic care to cancer patients. These strategies will hold in good stead for future pandemics also.

Imaging update in spinal tuberculosis

Tuberculosis is ancient disease known to mankind. Diagnosis and management of spinal tuberculosis has immensely improved in last few decades. Imaging, particularly MRI, plays important role in diagnosis of spinal tuberculosis and its complications. Four common imaging patterns of spinal tuberculosis include paradiscal type, central type, Anterior subligamentous type, and posterior type. Imaging also plays important role in differentiation of spinal tuberculosis from its mimics, particularly pyogenic spondylitis, and metastasis. Radiological interventions, such as CT guided vertebral biopsy, and percutaneous drainage of cold abscess, are commonly used in management of spinal tuberculosis. Monitoring of therapeutic response is often based on clinical evaluation and imaging. MRI is most common imaging modality used. Signs of healing include bony ankylosis, resolution of marrow edema, decrease in contrast enhancement, and fatty change with in bone marrow. PET CT is recently evaluated for response assessment with promising results. This review summarizes pathophysiology, clinical presentation, imaging features, radiological interventions, and response assessment in spinal tuberculosis.

Comparison of two forced air warming systems for prevention of intraoperative hypothermia in carcinoma colon patients: a prospective randomized study

Hypothermia is common occurrence in patients undergoing colonic surgeries. We hypothesized that the underbody forced air warming blankets will be better than conventional over-body forced air warming blankets for prevention of hypothermia during laparoscopic colon surgeries. After ethics approval, sixty patients undergoing elective laparoscopic colon surgeries were randomly divided into two groups to receive warming by underbody forced air warming blanket (n = 30) or over-body forced air warming blanket (n = 30). In the operating room, epidural catheter was inserted and thereafter warming was started with the forced air warmer with temperature set at 44 °C. Intraoperatively core temperature (using nasopharyngeal probe), vitals, incidence of postoperative shivering and time to reach Aldrete Score of 10 in the postoperative period were recorded. The core temperature was higher with an underbody blanket at 60 min (36.1 ± 0.5 °C vs. 35.7 ± 0.5 °C, P = 0.005), 90 min (35.9 ± 0.5 °C vs. 35.6 ± 0.5 °C, P = 0.009), 120 min (35.9 ± 0.5 °C vs. 35.5 ± 0.4 °C, P = 0.007), and 150 min (35.9 ± 0.5 °C vs. 35.6 ± 0.4 °C, P = 0.011). In the post anesthesia care unit, the time to reach an Aldrete score of 10 was also less in the underbody blanket group (14.3 ± 2.5 min vs. 16.8 ± 3.6 min) (P = 0.003). However, there were no clinically meaningful differences in any outcome. Underbody and over-body blankets were comparably effective in preventing hypothermia in patients undergoing laparoscopic colorectal surgery under general anaesthesia.Trial registration CTRI (2019/06/019,576). Date of Registration: June 2019, Prospectively registered.

El-Ganzouri multivariate risk index based airway management in head and neck cancer patients: A retrospective analysis of 1000 patients in a tertiary care center

BACKGROUND AND AIMS

Intubation in head and neck carcinoma (HNC) is difficult due to many reasons. Various guidelines recommend strategies for airway management in such anticipated difficult airway cases. However, literature is limited on airway management planning as per the level of difficulty based on airway assessment in these patients. EL-Ganzouri risk index (EGRI) has been proposed to aid in making airway management plan in HNC cases by some authors. This retrospective study was conducted to look at the data related to the pre-anesthetic airway assessment and the airway management plan executed by the anesthesiologists in 1000 patients of HNC in the previous nearly four years in order to determine how the choices made conformed to EGRI scores.

MATERIAL AND METHODS

Records of all the patients with oral cancer posted for surgery over four years from January 2014 to December 2017 were retrospectively analyzed for preoperative airway assessment using El Ganzouri risk index assessment (EGRI), the intraoperative technique for nasotracheal intubation, airway management plan, and any intraoperative complications.

RESULTS

The risk of predicted airway difficulty was low (EGRI <4) in 38 patients and was high in the rest. The EGRI score was higher in the FOB group [4-9] as compared to DL [2-3] and VL [1-6]. The patients with EGRI >7 were intubated awake and those with EGRI <7 were intubated under general anesthesia (79.8%). Overall, the technique of choice for intubation was fibreoptic bronchoscopy (54%) followed by video laryngoscopy (42.6%).

CONCLUSION

The airway management plan used in a tertiary care cancer center conformed to the approach suggested by the multivariate El Ganzouri risk index (EGRI). EGRI appears to be a useful means to ascertain the appropriate strategies for intubation in head and neck cancer patients.

BLS courses for refugees are feasible and induce commitment towards lay rescuer resuscitation

BACKGROUND

High-quality Basic Life Support (BLS), the first step in the Utstein formula for survival, needs effective education for all kinds of population groups. The feasibility of BLS courses for refugees is not well investigated yet.

METHODS

We conducted BLS courses including automated external defibrillator (AED) training for refugees in Austria from 2016 to 2019. Pre-course and after course attitudes and knowledge towards cardiopulmonary resuscitation (CPR) were assessed via questionnaires in the individuals' native languages, validated by native speaker interpreters.

RESULTS

We included 147 participants (66% male; 22 [17-34] years; 28% <18 years) from 19 countries (74% from the Middle East). While the availability of BLS courses in the participants' home countries was low (37%), we noted increased awareness towards CPR and AED use after our courses. Willingness to perform CPR increased from 25% to 99%. A positive impact on the participants' perception of integration into their new environment was noted after CPR training. Higher level of education, male gender, age <18 years and past traumatizing experiences positively affected willingness or performance of CPR.

CONCLUSION

BLS education for refugees is feasible and increases their willingness to perform CPR in emergency situations, with the potential to improve survival after cardiac arrest. Individuals with either past traumatizing experiences, higher education or those <18 years might be eligible for advanced life support education. Interestingly, these BLS courses bear the potential to foster resilience and integration. Therefore, CPR education for refuge should be generally offered and further evaluated.

Impact of COVID-19 Pandemic on Cancer Surgical Services-AIIMS, New Delhi Experience

COVID pandemic has impacted cancer care delivery and cancer surgical services globally. There is an urgent need to study the extent of the impact of COVID on cancer surgery and individual institutional response and strategies adopted to counter the adverse impact. A review of administrative and clinical policy changes adopted at the tertiary cancer center to combat COVID pandemic and resume cancer surgical services were performed. A retrospective comparative analysis of cancer out-patient census during COVID pandemic affected year and the preceding normal year along with cancer surgery data audit for the same periods was performed to assess the impact of the pandemic on cancer surgery. In addition, COVID infection rates among cancer surgery patients and healthcare workers were evaluated. There was approximately a 50% reduction in cancer outpatient registrations during COVID pandemic affected year. A trend of increasing footfalls was noted with decreasing COVID intensity and opening of lockdowns. There was a 33% reduction in major elective surgery and a 41% reduction in emergency surgery performed during the COVID period. As far as cancer surgeries are concerned, there was a 12-50% reduction in volumes involving different subsites. Overall COVID positivity rates among cancer surgery patients was low (8.17%), and approximately 30% of healthcare workers involved in cancer surgery were tested positive for COVID during the study period. Results of the current study indicate a significant impact of COVID pandemic on cancer surgical services. There was a significant impact on outpatient visits and cancer surgery volumes. However, a multidisciplinary-coordinated team approach, effective administrative and policy implementation, adoption of revised surgical safety and anesthesia protocols, COVID screening, and testing protocols facilitated resumption of cancer surgical services without adverse impact on surgical outcomes.

Impact of Standardized Educational Intervention on Improvement in Analgesic Knowledge and Its Compliance among Patients of Advanced Cancer Patients Attending Palliative Clinic: Prospective Randomized Study

Patient education is a low-cost intervention that can help in improving the knowledge and compliance regarding analgesics. This study aimed to assess the effectiveness of the standardized educational intervention on knowledge regarding analgesic, its compliance, and barriers to compliance among advanced cancer patients attending palliative care clinic.In this randomized control trial, 100 advanced cancer patients with pain were randomly allocated to two groups. A standardized educational intervention of 10-15 minutes on cancer pain management and analgesics was delivered at clinic visit to the patients in the intervention group at baseline and the control group received usual care. Analgesic knowledge, analgesic compliance, and barriers to compliance were measured for each patient at baseline, 2 and 4 weeks follow up visit. The data was analyzed and p < 0.05 was considered significant.Analgesic knowledge (p = 0.001) and compliance (p = 0.001) improved significantly in the experimental group at 2 weeks and 4 weeks as compared to the control group. There was also a statistically significant decrease in barriers to compliance in the experimental group as compared to the control group. A significant correlation between the knowledge and compliance score at 4 weeks in the experimental group was found with a Karl Pearson correlation coefficient, r = 0.628 (p = 0.001).The standardized educational intervention was found to be effective in improving the analgesic knowledge and analgesic compliance among cancer patients with pain at 2 and 4 weeks follow up as compared to the usual care.

Single-dose oral ivermectin in mild and moderate COVID-19 (RIVET-COV): A single-centre randomized, placebo-controlled trial

INTRODUCTION

Ivermectin is an antiparasitic drug which has in-vitro efficacy in reducing severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) viral load. Hence, Ivermectin is under investigation as a repurposed agent for treating COVID-19.

METHODS

In this pilot, double blind, randomized controlled trial, hospitalized patients with mild-to-moderate COVID-19 were assigned to a single oral administration of an elixir formulation of Ivermectin at either 24 mg or 12 mg dose, or placebo in a 1:1:1 ratio. The co-primary outcomes were conversion of RT-PCR to negative result and the decline of viral load at day 5 of enrolment. Safety outcomes included total and serious adverse events. The primary outcomes were assessed in patients who had positive RT-PCR at enrolment (modified intention-to-treat population). Safety outcomes were assessed in all patients who received the intervention (intention-to-treat population).

RESULTS

Among the 157 patients randomized, 125 were included in modified intention-to-treat analysis. 40 patients each were assigned to Ivermectin 24 mg and 12 mg, and 45 patients to placebo. The RT-PCR negativity at day 5 was higher in the two Ivermectin arms but failed to attain statistical significance (Ivermectin 24 mg, 47.5%; 12 mg arm, 35.0%; and placebo arm, 31.1%; p-value = 0.30). The decline of viral load at day 5 was similar in each arm. No serious adverse events occurred.

CONCLUSIONS

In patients with mild and moderate COVID-19, a single oral administration of Ivermectin did not significantly increase either the negativity of RT-PCR or decline in viral load at day 5 of enrolment compared with placebo.

Critical Care Management of the Parturient with Cardiac Disease

Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour.

HOW TO CITE THIS ARTICLE

Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.

Advanced dermatofibrosarcoma protuberans: an updated analysis of cases from an Indian sarcoma clinic

AIM

Dermatofibrosarcoma protuberans (DFSP) accounts for less than 2% of all soft-tissue sarcomas.

PATIENTS & METHODS

We retrospectively reviewed our database for patients with locally advanced or metastatic DFSP who had presented to our clinic between January 2016 and January 2020.

RESULTS

We identified a total of 14 patients, of whom ten had sarcomatous transformation. Eleven cases had metastatic disease and three were locally advanced. The initial partial response rate to first-line imatinib was 76.9% and the overall median progression-free survival on imatinib was 15 months.

CONCLUSION

We had a high proportion of patients with sarcomatous transformation, in contrast to their relative rarity in the West. While most patients had initial good responses to imatinib, second-line therapies were not as effective.

Comparative evaluation of glidescope videolaryngosocope and conventional macintosh laryngoscope for nasotracheal intubation in patients undergoing oropharyngeal cancer surgeries: A prospective randomized study

BACKGROUND AND AIMS

Nasotracheal intubation in oropharyngeal cancer patients is challenging owing to anatomical alterations. Various videolaryngoscopes have been compared to conventional laryngoscope and also amongst each other in different clinical scenarios; the supremacy of videolaryngoscopes over conventional laryngoscope in oropharyngeal cancer patients is yet to be established. We compared the efficacy of glidescope videolaryngoscopes and Macintosh laryngoscope for nasotracheal intubation in patients posted for routine oropharyngeal cancer.

MATERIAL AND METHODS

120 ASA I and II oropharyngeal cancer patients scheduled for elective surgery were randomized to undergo nasotracheal intubation after induction of general anesthesia with glide scope video laryngoscope (Group GVL, N = 60) or Macintosh laryngoscope (Group L, N = 60) as per group allocation. Time to glottic view, total intubation time (primary objective), hemodynamic fluctuations, and additional manoeuvres to aid intubation were recorded.

RESULTS

Time to visualize the glottic opening (9.20 ± 4.6 sec vs 14.8 ± 6.3 sec) (P = 0.000) and the total intubation time was significantly less in group GVL (35.6 ± 9.57 sec vs 42.2 ± 11 sec) (P = 0.001). Glidescope videolaryngosocpe provided better glottic views and resulted in significantly fewer manoeuvres to facilitate NTI (P = 0.009). The median numeric rating scale (NRS), hemodynamic parameters and complications were similar in both the groups.

CONCLUSION

Glidescope videolaryngosocpe is better than conventional Macintosh laryngoscope for intubation times and need of manoeuvres to facilitate intubation and should be a preferred device for NTI in patients with oropharyngeal cancer.

Perioperative anesthesia management for brachytherapy in cancer patients: A retrospective observational study

BACKGROUND AND AIMS

Anesthetic management for brachytherapy require repeated exposure to anesthesia in elderly patients with comorbidities. The varying locations provide an anesthesiologist with further challenges.

MATERIAL AND METHODS

We studied retrospectively anesthesia type, details of anesthetic techniques and complications that occurred in patients having received anesthesia for brachytherapy in our institute in the last 6 years. Categorical variables were described as frequency and percentage, and continuous variables described as median and interquartile range. For continuous variables, mean values compared using two sample t tests for independent samples.

RESULTS

The majority of patients were females who received brachytherapy for carcinoma cervix. A higher percentage of carcinoma breast and male genitourinary malignancies had comorbidities. Predominant side effects included 22 (1.85%) had hypotension, 19 (1.59%) had difficulty in putting spinal, 13 (1.09%) patients had tachycardia and 11 (0.92%) had headache in the postoperative period.

CONCLUSION

Neuraxial block as anesthetic technique in pelvic brachytherapy using fentanyl as additive helped reduce the dose of local anesthetic and avoided the complications of high spinal. The choice of anesthesia can vary depending on the duration and site of brachytherapy keeping in consideration the patient's factors.

Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC)

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Complementary and Alternative Modalities (CAM) for pain management in musculoskeletal diseases (MSDs)

Musculoskeletal diseases are a group of clinical conditions affecting the body's movement and remain a common source of pain affecting the quality of life. The aetio-pathological reasons for pain associated with musculoskeletal diseases can be varied and complex. Conventional medicine can treat or modify pain due to musculoskeletal diseases; however, these may be associated with some side effects and at times may not be able to relieve pain completely. These treatment modalities also have ceiling effects like doses of analgesics, the number of nerve blocks, etc. Complementary and Alternative Medicine (CAM) provides a supplementary, unconventional modality to alleviate discomfort and disability associated with these mostly chronic conditions to manage activities of daily living. These modalities have been variedly combined with conventional management for symptom control and thus improve day-to-day activities. We assess the role of commonly used CAM modalities in the management of pain arising from Musculoskeletal diseases.