Measuring endotracheal tube intracuff pressure: no room for complacency

Tracheal intubation constitutes a routine part in the care of critically ill and anaesthetised patients. Prolonged use of endotracheal with inflated cuff is one of the major multifactorial causes of complications. Both under-inflation and over-inflation of cuff are associated with complications. Despite known problems, regular measurement of cuff pressure is not routine, and it is performed on an ad hoc basis.

A qualitative study of the operating room experience of patients who underwent surgery under spinal anesthesia: "It was like an adventure"

This study aimed to explore the experiences of the people who underwent orthopedic surgery under spinal anesthesia and to report their feelings and thoughts. The study was carried out using a qualitative approach. Twenty-one patients were interviewed who underwent orthopedic surgery on the first or second postoperative day. Content analysis was performed after the collection of raw data. NVIVO 12 Pro software was used for data analysis. The frequency count (f) and participant codes (P) were used for the presentation of the findings. The themes and frequency counts obtained by analyzing the interviews with the patients were as follows: "Time passed like watching a movie" (f = 213), "Like an adventure" (f = 587), and "See, feel, look" (f = 405). Five of 21 participants (23.8%) stated that they would not recommend spinal anesthesia. The findings generally indicated the anxiety caused by the unknown, fear in the preanesthetic period, operation experienced like an adventure, and a process generally completed with satisfaction.

Diclofenac sodium loaded PLGA nanoparticles for inflammatory diseases with high anti-inflammatory properties at low dose: Formulation, characterization and in vivo HET-CAM analysis

The development of a new drug active substance is not only time-consuming and expensive, but also a chain of operations that often fails. However, increasing the bioavailability, effectiveness, safety, or targeting the drugs used in clinic by various methods, such as nanoparticles (NPs), may be a more effective way of using them in clinic. In addition, NP formulations are becoming increasingly popular in modern medical treatments. Angiogenesis, formation of new capillaries from a pre-existing one, fundamentally occurs in physiological processes such as wound healing, embryogenesis and menstrual cycle, also has a vital role in pathology of cancer, psoriasis, diabetic retinopathy and chronic inflammation. The Hen's Egg Test on the Chorioallantoic Membrane (HET-CAM) assay is a useful, well established and animal alternative in vivo procedure for evaluation of anti-inflammatory potentials and anti-irritant properties of nano drug delivery systems. In this study, diclofenac sodium (DS) loaded PLGA NPs were prepared and characterized. The particle size (PS) of DS-loaded PLGA NPs was between 114.7 and 124.8 nm and all NPs were monodisperse with negative zeta potential values. The encapsulation efficiency was in range of 41.4-77.8%. In vitro dissolution studies of NPs showed up to 24 h of DS release after the first 3 h of burst effect. The 3 h burst effect and 24 h release kinetics studied with DDSolver were found to be predominantly driven not only by one mechanism, by a combined mechanism of Fickian and non-Fickian. Solid state structures of formulations were clarified by DSC and FT-IR analysis. PS, EE% and release rates were found to be affected by the amount of DS added to the formulations. Increasing the amount of DS added to the formulations increased PS, while the EE% decreased. The release rates were affected by PS and the formulation with the lowest PS value showed slower release. The anti-inflammatory activity of optimum formulation (NP-1) was examined using in vivo HET-CAM assay. The anti-inflammatory activity results indicated that NP-1 coded NP formulation showed significantly good anti-inflammatory potential at low dose. As a result, a low dose high anti-inflammatory effect was achieved with the NP structure of DS. To the best of our knowledge this is the first study on in vivo anti-inflammatory activities of DS loaded PLGA NPs by HET-CAM.

New 2-amino-pyridinyl-N-acylhydrazones: Synthesis and identification of their mechanism of anti-inflammatory action

AIMS

The main aim of this paper was the synthesis and the evaluation of the anti-inflammatory activity of LASSBio-1828 (an amino-pyridinyl-N-acylhydrazone) and its respective hydrochloride, based on a p38α MAPK inhibitor (LASSBio-1824) previously synthesized by our group.

MAIN METHODS

The compounds were tested regarding their cell viability effect and on acute models of inflammation such as formalin-induced licking test, cell migration and inflammatory mediators quantification.

KEY FINDINGS

Treatment with the compounds inhibited p38α, reduced inflammatory pain, cell migration and inflammatory mediators that participate on the MAPK pathway such as TNF-α and IL-1β.

SIGNIFICANCE

Taken together, these results suggest that the synthesis of the corresponding hydrochloride of LASSBio-1828 enhanced its potency as a p38 inhibitor, and also that this compound could be considered a good anti-inflammatory drug candidate after further studies.

Phase I/II parallel double-blind randomized controlled clinical trial of perispinal etanercept for chronic stroke: improved mobility and pain alleviation

Background: Previous open-label studies showed that chronic post-stroke pain could be abated by treatment with perispinal etanercept, although these benefits were questioned. A randomized double-blind placebo controlled clinical trial was conducted to test perispinal etanercept for chronic post-stroke pain.Research design and methods: Participants received two treatments, either perispinal etanercept (active) or saline (control). Primary outcomes were the differences in daily pain levels between groups analyzed by SPSS.Results: On the 0-100 points visual analog scale, perispinal etanercept reduced mean levels for worst and average daily pain from baseline after two treatments by 19.5 - 24 points (p < 0.05), and pain alleviation was maintained in the etanercept group, with no significant change in the control group. Thirty percent of etanercept participants had near complete pain abatement after first treatment. Goniometry of the paretic arm showed improved mean shoulder rotation by 55 degrees in active forward flexion for the etanercept group (p = 0.003) only.Conclusions: Perispinal etanercept can provide significant and ongoing benefits for the chronic post-stroke management of pain and greater shoulder flexion by the paretic arm. Effects are rapid and highly significant, supporting direct action on brain function.Trial registration: ACTRN12615001377527 and Universal Trial Number U1111-1174-3242.

[Subjective method for tracheal tube cuff inflation: performance of anesthesiology residents and staff anesthesiologists. Prospective observational study]

BACKGROUND AND OBJECTIVES

Poor monitoring of tracheal tube cuff pressure may result in patient complications. The objective method of using a manometer is recommended to keep safe cuff pressure values (20-30 cm H₂O). However, as manometers are not readily available, anesthesiologists use subjective methods. We aimed to assess appropriateness of a subjective method for attaining cuff pressure and the expertise level of manometer handling among anesthesiology staff and residents in a university teaching hospital.

METHODS

Prospective observational study, recruiting participants that performed tracheal intubation and the subjective method for tube cuff inflation. Patients with difficult airway, larynx and trachea anatomic abnormality and emergency procedures were not included. Up to 60 minutes after tracheal intubation, an investigator registered the cuff pressure using an aneroid manometer (AMBU®) connected to the tube pilot balloon.

RESULTS

Forty-seven anesthesiologists were included in the study - 24 residents and 23 staff. Mean (SD) and medians (IQR) measured in cm H₂O were, respectively, 52.5 (27.1) and 50 (30-70). We registered 83% of measurements outside the recommended pressure range, with no difference between specialists and residents. The level of expertise with the objective method was also similar in both groups. Pressure adjustments were performed in 76.6% of cases.

CONCLUSION

The subjective method for inflating the tracheal tube cuff resulted in a high rate of inadequate cuff pressures, with no difference in performance between anesthesiology specialists and residents.

Subjective method for tracheal tube cuff inflation: performance of anesthesiology residents and staff anesthesiologists. Prospective observational study

Background and objectives

Poor monitoring of tracheal tube cuff pressure may result in patient complications. The objective method of using a manometer is recommended to keep safe cuff pressure values (20‒30 cm H₂O). However, as manometers are not readily available, anesthesiologists use subjective methods. We aimed to assess appropriateness of a subjective method for attaining cuff pressure and the expertise level of manometer handling among anesthesiology staff and residents in a university teaching hospital.

Methods

Prospective observational study, recruiting participants that performed tracheal intubation and the subjective method for tube cuff inflation. Patients with difficult airway, larynx and trachea anatomic abnormality and emergency procedures were not included. Up to 60 minutes after tracheal intubation, an investigator registered the cuff pressure using an aneroid manometer (AMBU®) connected to the tube pilot balloon.

Results

Forty-seven anesthesiologists were included in the study – 24 residents and 23 staff. Mean (SD) and medians (IQR) measured in cmH₂O were, respectively, 52.5 (27.1) and 50 (30‒70). We registered 83% of measurements outside the recommended pressure range, with no difference between specialists and residents. The level of expertise with the objective method was also similar in both groups. Pressure adjustments were performed in 76.6% of cases.

Conclusion

The subjective method for inflating the tracheal tube cuff resulted in a high rate of inadequate cuff pressures, with no difference in performance between anesthesiology specialists and residents.

Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis

PURPOSE

Acute urinary retention (AUR) is a common postoperative complication in colorectal surgery. In pelvic colorectal operations, the optimal duration for postoperative urinary catheter use is controversial. This systematic review and meta-analysis aims to compare early (POD 1), intermediate (POD 3), and late (POD 5) urinary catheter removal.

METHODS

Medline, EMBASE, CENTRAL, and PubMed databases were searched. Articles were eligible for inclusion if they compared patients with urinary catheter removal on POD 1 or earlier to patients with urinary catheter removal on POD 2 or later in major pelvic colorectal surgeries. The primary outcome was rate of postoperative AUR. The secondary outcome was rates of postoperative urinary tract infection (UTI).

RESULTS

From 691 relevant citations, five studies with 928 patients were included. Comparison of urinary catheter removal on POD 1 versus POD 3 demonstrated no significant difference in rate of urinary retention (RR 1.36, 95%CI 0.83-2.21, P = 0.22); however, compared to POD 5, rates of AUR were significantly higher (RR 2.58, 95%CI 1.51-4.40, P = 0.0005). Rates of UTI were not significantly different between POD 1 and POD 3 urinary catheter removal (RR 0.40, 95%CI 0.05-3.71, P = 0.45), but removal on POD 5 significantly increased risk of UTI compared to POD 1 (RR 0.50, 95%CI 0.31-0.81, P = 0.005).

CONCLUSION

Risk of AUR can be minimized with late postoperative urinary catheter removal compared to early removal, but at the cost of increased risk of UTI. Patient-specific factors should be taken into consideration when deciding upon optimal duration of postoperative urinary catheterization.

Extreme blood loss in cancer surgery: is it a verdict to the patient or a challenge to the staff?

Background. The development of anesthesiology allows performing combined operations in patients with locally advanced malignant tumors. A logical companion of aggressive cancer surgery is a massive blood loss, which can be so pronounced that it poses a threat to the life of the patient. Objective. The presented experience is an example of transformation of a nearly fatal situation into a curable one and can be useful in choosing an active treatment strategy in most desperate situations. Methods. This research includes 25 patients with the blood loss of 20 liters or more during surgery. Results. The median ratio of infusion to blood loss was 133%, and the ratio of the infusion to all fluid losses amounted to 118%. In 100% of cases, catecholamines were used to support the blood circulation: one drug used in 12% of observations and two to five drugs used in 88% of observations. 2 patients died during the operation. 5 patients died in the early postoperative period from multiple organ failure. The cause of death of another 5 patients was septic complications before the 28th post-op day. Discussion. Performing operations accompanied by acute massive blood loss requires an effective anesthetic support. Conclusions. Enforcement of certain diagnostic and therapeutic conditions (stage construction of anesthesia, hemodynamic and laboratory monitoring, adequate venous access, rational infusion, timely use of catecholamines, using cell-saver device) in the majority of cases allows completing the operation with the surgical control of hemostasis and successfully enduring traumatic and complicated surgery in half of cases.

Understanding sciatica: illness and treatment beliefs in a lumbar radicular pain population. A qualitative interview study

BACKGROUND

Several pathological processes contribute to lumbar radicular pain (LRP), commonly known as sciatica. It is not known how patients rationalise the experience of sciatica or understand the diagnosis. Providing clinicians with a better understanding of how patients conceptualise sciatica will help them to tailor information for patients on the management and treatment of the condition.

AIM

To understand patients' beliefs regarding their illness following a diagnosis of LRP, how these beliefs were developed, and the impact of illness beliefs on treatment beliefs.

DESIGN & SETTING

Qualitative interview study from a single NHS musculoskeletal interface service (in Wales, UK).

METHOD

Thirteen patients recently diagnosed with LRP were consecutively recruited. Individual semi-structured interviews were recorded and transcribed. Data were analysed using a thematic approach.

RESULTS

Four main themes were generated: (1) the illness experience (2) the concept of sciatica, (3) treatment beliefs, and (4) the desire for credible information.

CONCLUSION

The diagnosis of LRP is often communicated and understood within a compressive conceptual illness identity. Explaining symptoms with a compressive pathological model is easily understood by patients but may not accurately reflect the spectrum of pathological processes known to contribute to radicular pain. This model appears to inform patient beliefs about treatments. Clinicians should take care to fully explain the pathology prior to shared decision-making with patients.

Shock index in patients with traumatic solid organ injury as a predictor of massive blood transfusion protocol activation

Purpose

We aimed to assess the utility of shock index (SI) to predict the need for massive transfusion protocol (MTP) in patients with solid organ injury (SOI) in a Level 1 Trauma center.

Methods

We conducted a retrospective analysis for patients with SOI between 2011 and 2014. Patients were categorized according to on-admission SI into low (< 0.8) and high SI (≥0.8) group.

Results

A total of 4500 patients were admitted with trauma, of them 572 sustained SOIs (289 patients had SI ≥0.8). In comparison to low SI, patients with high SI were younger, had higher injury severity scores (ISS) and lower Trauma and Injury Severity Score (TRISS); (p < 0.001). The proportion of exploratory laparotomy (EXLap), blood transfusion (BT), MTP activation, sepsis and hospital mortality were significantly higher in patients with high SI. Serum lactate (r = 0.34), hematocrit (r = − 0.34), ABC score (r = 0.62), ISS (r = 0.35), and amount of transfused blood (r = 0.22) were significantly correlated with SI. On multivariable regression analysis using 9 relevant variables (age, sex, ISS, ED GCS, serum lactate, hematocrit, Abdomen AIS and Focused assessment with sonography in trauma (FAST) and SI), SI ≥ 0.8 was an independent predictor of BT (OR 2.80; 95%CI 1.56–4.95) and MTP (OR 2.81;95% CI 1.09–7.21) .

Conclusions

In patients with SOI, SI is a simple bedside predictor for BT and MTP activation. Further prospective studies are needed to support our findings.

Anesthetic Management of the Narrowed Airway

Airway narrowing can be idiopathic or can occur as a result of airway tumors, hematomas, infections, and other pathologic conditions. Endoscopic management variously involves balloon dilatation, stent placement, laser vaporization of pathologic tissue, microdebridement, and other interventions, using either a rigid or a flexible bronchoscope. Jet ventilation is frequently used in such settings, especially when the presence of an endotracheal tube would interfere with the procedure. In desperate cases, extracorporeal membrane oxygenation may be used in managing the critical airway.

Long-term Outcome of Intravenous Lidocaine in Pediatric Cluster Seizures: A Preliminary Study

BACKGROUND

Cluster seizures are life-threatening conditions. They may easily evolve into status epilepticus and are reported in up to 20% to 30% of patients with epilepsy. Sometimes cluster seizures become drug resistant, leading to the use of unconventional therapies. One of these unconventional approaches may be the use of lidocaine, which is a sodium-channel-blocking drug mostly known as a local anesthetic and antiarrhythmic agent.

METHODS

We describe the outcome of four children who were treated with continuous intravenous infusion of 2% lidocaine due to drug-resistant focal cluster seizures. Lidocaine was administered as an initial dose of 1 mg/kg/hour and, subsequently, was increased to 2 to 4 mg/kg/hour. The therapy was continued for five to 10 days. Patients remained under careful cardiological surveillance during the treatment.

RESULTS

Complete seizure remission was achieved in all four children. None of the patients experienced adverse events. Although seizures recurred in all patients within an average time of 2.4 months, they appeared with reduced frequency, and within the follow-up period (mean 7.5 months) no additional cluster seizures occurred.

CONCLUSIONS

Treatment with lidocaine in pediatric cluster seizures may be useful and may be considered as a therapeutic option. Our patients encountered no side effects and experienced prolonged seizure remission, possibly resulting from the effect of lidocaine on sodium channels or from its anti-inflammatory properties. However, more studies are required to confirm the safety and long-term effectiveness of this approach. Clinicians should be aware of possible adverse effects and necessity of sustained cardiological surveillance during the treatment.

Medications for pain relief in outpatient endometrial sampling or biopsy: a systematic review and network meta-analysis

OBJECTIVE

To determine the most effective analgesia for pain relief during the outpatient endometrial biopsy (OEB) or outpatient hysteroscopy with endometrial aspiration (EA).

DESIGN

Systematic review and network meta-analysis of randomized controlled trials.

SETTING

Not applicable.

PATIENT(S)

Pre- or postmenopausal women undergoing OEB or outpatient hysteroscopy with EA for evaluation of uterine pathology.

INTERVENTION(S)

We conducted an electronic search of the following bibliographic databases: Medline via PubMed, SCOPUS, Web of Science, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL).

MAIN OUTCOME MEASURE(S)

The intensity of pain during, immediately after, and 10-30 minutes after procedure assessed by the 10-cm visual analog scale.

RESULT(S)

Lidocaine spray was the most effective medication for reducing pain during OEB (P-score = 0.83) and immediately after OEB (P-score = 0.96). On the other hand, naproxen sodium was the most effective medication for reducing pain during outpatient hysteroscopy with EA (P-score = 1.00), followed by misoprostol plus lidocaine (P-score = 0.87).

CONCLUSION(S)

Lidocaine spray, either alone or with topical application of lidocaine, is the most effective medication for reducing the pain during and after the OEB. Naproxen sodium is the most effective analgesic option during outpatient hysteroscopy with EA.

Flow rate accuracy of ambulatory elastomeric and electronic infusion pumps when exposed to height and back pressures experienced during home infusion therapy

Background: Elastomeric infusion pumps are widely used in the delivery of parenteral medications in the home, but real-life conditions may not match calibration or standardised testing conditions. This study investigated the impact of changes in infusion pump height and/or back pressure on infusion pump function. Methods: Volume delivered after one day, infusion duration, average and peak flow rates and time spent within stated accuracy were determined for four elastomeric and one electronic pump using gravimetric technique. Experiments were repeated after altering the height of the pump relative to the output (±40cm, ±20cm) and/or adding a back pressure (10-30mmHg) to the output of an attached catheter. Results: Under ideal operating conditions, the flow rate deviated from that specified by the manufacturer and between 88.5% and 99% of the total infusion volume was delivered. Varying the height or applying back pressure led to further changes in average flow rates and the volume of infusion solution delivered by the elastomeric pumps, but had little effect on the electronic pump. Conclusions: Clinicians should consider potential impact on drug delivery, safety and therapeutic effect for home infusion patients given variations in infusion pump performance observed in this study.

Electrochemotherapy of superficial tumors - Current status:: Basic principles, operating procedures, shared indications, and emerging applications

Treatment of superficial tumors with electrochemotherapy (ECT) has shown a steep rise over the past decade and indications range from skin cancers to locally advanced or metastatic neoplasms. Based on reversible electroporation, which is a physical method to achieve transient tumor cell membrane permeabilization by means of short electric pulses, ECT increases cellular uptake of bleomycin and cisplatin and their cytotoxicity by 8,000- and 80-fold, respectively. Standard operating procedures were established in 2006 and updated in 2018. Ease of administration, patient tolerability, efficacy across histotypes, and repeatability are peculiar advantages, which make standard ECT (ie, ECT using fixed-geometry electrodes) a reliable option for controlling superficial tumor growth locally and preventing their morbidity. Consolidated indications include superficial metastatic melanoma, breast cancer, head and neck skin tumors, nonmelanoma skin cancers, and Kaposi sarcoma. In well-selected patients with oropharyngeal cancers, ECT ensures appreciable symptom control. Emerging applications include skin metastases from visceral or hematological malignancies, vulvar cancer, and some noncancerous skin lesions (keloids and capillary vascular malformations). Repeatability and integration with other oncologic therapies allow for consolidation of response and sustained tumor control. In this review, we present the basic principles of ECT, recently updated operating procedures, anesthesiological management, and provide a synthesis of the efficacy of standard ECT across histotypes.

Tabebuia aurea decreases hyperalgesia and neuronal injury induced by snake venom

ETHNOPHARMACOLOGICAL RELEVANCE

Tabebuia aurea (Silva Manso) Benth. & Hook. f. ex S. Moore is used as anti-inflammatory, analgesic and antiophidic in traditional medicine, though its pharmacological proprieties are still underexplored. In the bothropic envenoming, pain is a key symptom drove by an intense local inflammatory and neurotoxic event. The antivenom serum therapy is still the main treatment despite its poor local effects against pain and tissue injury. Furthermore, it is limited to ambulatorial niches, giving space for the search of new and more inclusive pharmacological approaches.

AIM OF THE STUDY

evaluation of Tabebuia aurea hydroethanolic extract (HEETa) in hyperalgesia and neuronal injury induced by Bothrops mattogrossensis venom (VBm).

MATERIALS AND METHODS

Stem barks from Tabebuia aurea were extracted with ethanol and water (7:3, v/v) to yield the extract HEETa. Then, HEETa was analyzed by LC-DAD-MS and its constituents were identified. Snake venoms were extracted from adult specimens of Bothrops mattogrossensis, lyophilized and kept at -20 °C until use. Male Swiss mice, weighting 20-25 g, were used to hyperalgesia (electronic von Frey), motor impairment (Rotarod test) and tissue injury evaluation (histopatology and ATF-3 immunohistochemistry). Therefore, three experimental groups were formed: VBm (1 pg, 1 ng, 0.3 μg, 1 μg, 3 and 6 μg/paw), HEETa orally (180, 540, 720, 810 or 1080 mg/kg; 10 mL/kg, 30 min prior VBm inoculation) and VBm neutralized (VBm: HEETa, 1:100 parts, respectively). In all set of experiments a control (saline group) was used. First, we made a dose-time-response course curve of VBm's induced hyperalgesia. Next, VBm maximum hyperalgesic dose was employed to perform HEETa orally dose-time-response course curve and analyses of VBm neutralized. Paw tissues for histopathology and DRGs were collected from animals inoculated with VBm maximum dose and treated with HEETa antihyperalgesic effective dose or neutralized VBm. Paws were extract two or 72 h after VBm inoculation and DRGs, in the maximum expected time expression of ATF-3 (72 h).

RESULTS

From HEETa extract, glycosylated iridoids were identified, such as catalpol, minecoside, verminoside and specioside. VBm induced a time and dose dependent hyperalgesia with its highest effect seen with 3 µg/paw, 2 h after venom inoculation. HEETa effective dose (720 mg/kg) decreased significantly VBm induced hyperalgesia (3 µg/paw) with no motor impairment and signs of acute toxicity. HEETa antihyperalgesic action starts 1.5 h after VBm inoculation and lasted up until 2 h after VBm. Hyperalgesia wasn't reduced by VBm: HEETa neutralization. Histopathology revealed a large hemorragic field 2 h after VBm inoculation and an intense inflammatory infiltrate of polymorphonuclear cells at 72 h. Both HEETa orally and VBm: HEETa groups had a reduced inflammation at 72 h after VBm. Also, the venom significantly induced ATF-3 expression (35.37 ± 3.25%) compared with saline group (4.18 ± 0.68%) which was reduced in HEETa orally (25.87 ± 2.57%) and VBm: HEETa (19.84 ± 2.15%) groups.

CONCLUSION

HEETa reduced the hyperalgesia and neuronal injury induced by VBm. These effects could be related to iridoid glycosides detected in HEETa and their intrinsic reported mechanism.

Intravenous lidocaine infusion as a component of multimodal analgesia for colorectal surgery-measurement of plasma levels

Background

Growing evidence suggests that intravenous lidocaine as a component of multimodal analgesia improves recovery after major colorectal surgery. There is little published data regarding ideal dosing and target plasma concentration in this context, and we wanted to establish our dosing schedule was safe by measuring blood levels of lidocaine.

Methods

We measured the plasma lidocaine concentration of 32 patients at 30 min, 6 h and 12 h after starting intravenous lidocaine infusion for analgesia after major colorectal surgery. Patients received a bolus of 1.5 mg kg⁻¹ over 20 min at the time of induction of anaesthesia. This was followed by a continuous infusion of 2% w/v lidocaine at 3 ml hr⁻¹ (60 mg hr⁻¹) for patients weighing up to 70 kg and 6 ml hr⁻¹ (120 mg hr⁻¹) for patients weighing over 70 kg, using actual body weight.

Results

The overall mean plasma lidocaine concentration was 4.0 μg ml⁻¹ (range 0.6–12.3 μg ml⁻¹). In patients treated with the higher infusion dose, the mean concentration was 4.6 μg ml⁻¹ compared to 3.2 μg ml⁻¹ in those patients on the lower dose. Mean levels were higher at 6 h than 30 min and higher again at 12 h. There were no adverse events or reports of symptoms of local anaesthetic toxicity.

Conclusions

Whilst there were no signs or symptoms of lidocaine toxicity in our patients, there was a wide range of plasma concentrations including some over 10 μg ml⁻¹; a level above which symptoms of toxicity may be expected. We have changed our dosing protocol to using ideal rather than actual body weight based on these results.

Comparison of the Efficacy of Intrathecal Isobaric Ropivacaine and Bupivacaine in Day Care Knee Arthroscopy: A Randomized Controlled Trial

Background:

The primary goal of ambulatory anesthesia is a rapid recovery with minimal side effects. Ropivacaine, due to its property of sensory-motor dissociation, maybe a useful agent when equivalent spinal anesthesia and quicker recovery of motor function is desirable.

Aim:

The aim of this study is to compare the efficacy of intrathecal isobaric ropivacaine with bupivacaine and to assess their postoperative recovery profile in patients undergoing arthroscopic knee surgery.

Setting and Design:

This randomized controlled study was conducted at a tertiary care hospital.

Materials and Methods:

A total of 90 adult American Society of Anaesthesiologist physical status Classes 1 and 2 patients were randomized into two groups to receive 2 ml plain solution of either 0.5% bupivacaine (Group B) or 0.75% ropivacaine (Group R). In the intraoperative period, onset, efficacy, duration, and regression of sensory and motor block were noted in both the groups at regular intervals. Postoperatively, the groups were compared for pain score, recovery profile, analgesic requirement, and complications.

Statistical Analysis:

Data analysis was performed using Chi-square test and Student's t-test.

Results:

The mean onset time of sensory block at L1 was significantly less (P = 0.025) and duration of sensory and motor block was significantly more (P = 0.001) with bupivacaine as compared to ropivacaine. The analgesic requirement on the 1^st postoperative day (P = 0.011) and incidence of delayed voiding of urine (P = 0.022) were significantly more with ropivacaine. The postoperative recovery profile and discharge times were similar between the groups.

Conclusion:

Isobaric ropivacaine was associated with a longer onset and shorter duration of sensory and motor block, increased postoperative analgesic requirement, higher complication rate, and similar discharge times as compared with bupivacaine. Therefore, isobaric bupivacaine may be preferred over isobaric ropivacaine for day care knee arthroscopy, especially in cases with an anticipated longer duration of surgery.

Anesthetic management of a patient with an unusual broken tracheostomy tube: a case report

Objective

This study was performed to investigate the management of general anesthesia in an unusual case involving a patient with a broken tracheostomy tube presenting as an airway foreign body.

Methods

We herein describe the anesthetic management of a patient with a broken tracheostomy tube. A 77-year-old Chinese man who had been involved in a car accident underwent a tracheostomy. One year later, he presented with cough and bleeding at the tracheostomy site. Preoperative evaluation revealed that the metal tracheostomy tube was lodged in his left main bronchus. General anesthesia was induced to maintain spontaneous breathing, and adequate topical anesthesia of the airway was administered.

Results

The metal tracheostomy tube was successful removed, and a new tracheal tube was put in place.

Conclusions

General anesthesia to maintain spontaneous breathing and adequate topical anesthesia of the airway can be safely used when removing broken tracheostomy tubes.

Current challenges in diagnosis of lumbar radiculopathy

Lumbar radiculopathy (LR) is a term used to describe a pain syndrome caused by compression or irritation of nerve roots in the lower back. The surgery cost for LR increased by 23% annually during 1992-2003 in the developed country. Although it is one of most common complaints in clinical practice, the diagnosis for LR is still very challenging. Here we discuss the current tools of LR diagnosis and highlight the needs to develop new diagnosis tools for LR.

Neuraxial Anesthesia in the Geriatric Patient

Neuraxial anesthesia is recommended as a well-accepted option to minimize the perioperative side effects in the geriatric patients. The available data from the current researches have shifted the focus from the conventional approach to spinal anesthesia to the concept of low dose local anesthetic combined with opioids. What remains clear from all these studies is that hemodynamic stability is much better in patients who received low-doses of intrathecal bupivacaine in combination with opioids, which is possibly result of a potent synergistic nociceptive analgesic effect and their minimal potential effects on sympathetic pathways thus minimizing spinal hypotension. Spinal anesthesia with 5–10 mg of 0.5% heavy bupivacaine, fentanyl 20 mcg and 100 mcg of long-acting morphine added to the perioperative plan decreased the incidence of spinal hypotension and improved perioperative outcomes in the geriatric patients undergoing (low segment) surgical procedures. These findings may be of interest in the gynecologic geriatric surgery also in which area there are very few studies concerning the use of low-dose concept.

The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal

BACKGROUND

Sex research lacks experimental studies in which both partners participate in a laboratory procedure. This is relevant in the context of genital pain because painful vaginal sensations often occur in the presence of the partner.

AIM

To examine the effects of partner presence, sexual stimulation, and vaginal pressure on the appraisal of vaginal sensations and sexual arousal, ultimately aiming to increase the ecologic validity of laboratory designs.

METHODS

A community sample of 42 women and their male partners watched sexual and neutral films while separated or together. We induced gradually increasing vaginal pressure in the women using an intravaginal inflatable rubber balloon.

OUTCOMES

Women reported on pleasant and painful vaginal pressure and perceived genital arousal. Men and women reported on subjective sexual arousal. We also examined whether these appraisals were moderated by relationship satisfaction.

RESULTS

The appraisal of vaginal pressure varied as a function of relationship satisfaction. Less satisfied women reported more painful pressure than women who were highly satisfied and highly satisfied women appraised the pressure as more pleasant in the context of a sex film and in the presence (vs absence) of their partner. In men and women, although partner presence had a negative effect on subjective sexual arousal, the presence of the partner did increase women's perception of genital arousal when vaginal pressure was induced during a sex film, particularly when women felt highly satisfied with their relationship. Also, the effects on subjective sexual arousal were moderated by relationship satisfaction. For couples in which the woman was less satisfied, the induction of vaginal pressure resulted in higher subjective sexual arousal when the partner was absent compared with when he was present, whereas when the man felt less satisfied, partner presence had a positive effect on sexual arousal.

CLINICAL IMPLICATIONS

Interventions need to focus on the importance of sexual arousal during vaginal pressure stimulation and the way this is shaped by partner and relationship variables. Our results indicate that enhancing the relationship climate is an important target of intervention.

STRENGTHS AND LIMITATIONS

We did not include physical indices of genital arousal and did not use a clinical sample of women with genital pain.

CONCLUSIONS

The appraisal of vaginal sensations and sexual arousal are context-dependent responses that vary as a function of partner presence and sexual stimulation. Including both partners in the laboratory setting is important to create more valid models on sexual responding. Dewitte M, Schepers J, Melles R. The Effects of Partner Presence and Sexual Stimulation on the Appraisal of Vaginal Pressure and Sexual Arousal. J Sex Med 2018;15:539-549.

Intravenous lidocaine infusion

Systemic lidocaine used in continuous infusion during the peri-operative period has analgesic, anti-hyperalgesic, as well as anti-inflammatory properties. This makes it capable of reducing the use of opioids and inhalational anaesthetics, and the early return of bowel function, and patient hospital stay. The aim of this narrative review was to highlight the pharmacology and indications for clinical application, along with new and interesting research areas. The clinical applications of peri-operative lidocaine infusion have been reviewed in several recent systematic reviews and meta-analyses in patients undergoing open and laparoscopic abdominal procedures, ambulatory procedures, and other types of surgery. Peri-operative lidocaine infusion may be a useful analgesic adjunct in enhanced recovery protocols. Potential benefits of intravenous lidocaine in chronic post-surgical pain, post-operative cognitive dysfunction, and cancer recurrence are under investigation. Due to its immunomodulation properties over surgical stress, current evidence suggests that intravenous lidocaine could be used in the context of multimodal analgesia.

Fracture and aspiration of tracheostomy tube: A case report

Fracture and aspiration of tracheostomy tube is a rare late complication of the tracheostomized patient. We report a case of a 30-year-old male patient, who was tracheostomized 2 years ago for prolonged ventilation secondary to organophosphorus poisoning. He presented with history of minimal cough without any respiratory distress and was otherwise hemodynamically stable. The chest x-ray showed a metal tube lodged in the left main bronchus. The aspirated tracheostomy tube was removed by flexible bronchoscopy without any complications. Through this case, the authors highlight the need for proper care of a tracheostomy tube and also a rare complication of tracheostomy tube.

The NAPRESSIM trial: the use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine in elective hepatobiliary surgery: a study protocol and statistical analysis plan for a randomised controlled trial

BACKGROUND

Intrathecally administered morphine is effective as part of a postoperative analgesia regimen following major hepatopancreaticobiliary surgery. However, the potential for postoperative respiratory depression at the doses required for effective analgesia currently limits its clinical use. The use of a low-dose, prophylactic naloxone infusion following intrathecally administered morphine may significantly reduce postoperative respiratory depression. The NAPRESSIM trial aims to answer this question.

METHODS/DESIGN

'The use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine' trial is an investigator-led, single-centre, randomised, double-blind, placebo-controlled, double-arm comparator study. The trial will recruit 96 patients aged > 18 years, undergoing major open hepatopancreaticobiliary resections, who are receiving intrathecally administered morphine as part of a standard anaesthetic regimen. It aims to investigate whether the prophylactic administration of naloxone via intravenous infusion compared to placebo will reduce the proportion of episodes of respiratory depression in this cohort of patients. Trial patients will receive an infusion of naloxone or placebo, commenced within 1 h of postoperative extubation continued until the first postoperative morning. The primary outcome is the rate of respiratory depression in the intervention group as compared to the placebo group. Secondary outcomes include pain scores, rates of nausea and vomiting, pruritus, sedation scores and adverse outcomes. We will also employ a novel, non-invasive, respiratory minute volume monitor (ExSpiron 1Xi, Respiratory Motion, Inc., 411 Waverley Oaks Road, Building 1, Suite 150, Waltham, MA, USA) to assess the monitor's accuracy for detecting respiratory depression.

DISCUSSION

The trial aims to provide a clear management plan to prevent respiratory depression after the intrathecal administration of morphine, and thereby improve patient safety.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02885948 . Registered retrospectively on 4 July 2016. Protocol Version 2.0, 3 April 2017. Protocol identification (code or reference number): UCDCRC/15/006 EudraCT registration number: 2015-003504-22. Registered on 5 August 2015.

How nurse gender influences patient priority assignments in US emergency departments

The goals of this study were to compare whether emergency department (ED) patients' pain intensity (PI) is measured differently by male and female nurses and to determine whether PI, heart rate (HR), and respiratory rate (RR) were used to prioritize patient urgency differently by male and female nurses. The associations between patients' PI|HR|RR and the Emergency Severity Index (ESI) scores they were assigned by attending nurses were analyzed using a national database of electronic medical records of US Veterans Affairs ED patients from 2008 to 2012. A total of 129,991 patients presenting for emergency care (Mage = 59.5, 92% males) and their triage nurses (n = 774, Mage = 47.5, 18% males) were analyzed, resulting in a total of 359,642 patient-provider interactions. Patients' PI did not differ by the nurse's gender; however a cross-classified mixed-effects model showed that nurse gender influenced how PI and RR measurements informed the ESI levels that male patients received. Higher PI levels were associated with more urgent (higher priority) ESI levels by female nurses, yet less urgent ESI levels by male nurses. In contrast, male patients with high RR received more urgent ESI levels by male nurses, whereas the nurse gender did not influence ESI assignments for female patients. These findings show that ED patients receive disparate treatment based on inherent characteristics of their triage nurses, and more standardized (eg, automated) protocols that can account for implicit social factors on health care practice for reliably assessing and prioritizing ED patients may be currently warranted.

Challenges in translational drug research in neuropathic and inflammatory pain: the prerequisites for a new paradigm

AIM

Despite an improved understanding of the molecular mechanisms of nociception, existing analgesic drugs remain limited in terms of efficacy in chronic conditions, such as neuropathic pain. Here, we explore the underlying pathophysiological mechanisms of neuropathic and inflammatory pain and discuss the prerequisites and opportunities to reduce attrition and high-failure rate in the development of analgesic drugs.

METHODS

A literature search was performed on preclinical and clinical publications aimed at the evaluation of analgesic compounds using MESH terms in PubMed. Publications were selected, which focused on (1) disease mechanisms leading to chronic/neuropathic pain and (2) druggable targets which are currently under evaluation in drug development. Attention was also given to the role of biomarkers and pharmacokinetic-pharmacodynamic modelling.

RESULTS

Multiple mechanisms act concurrently to produce pain, which is a non-specific manifestation of underlying nociceptive pathways. Whereas these manifestations can be divided into neuropathic and inflammatory pain, it is now clear that inflammatory mechanisms are a common trigger for both types of pain. This has implications for drug development, as the assessment of drug effects in experimental models of neuropathic and chronic pain is driven by overt behavioural measures. By contrast, the use of mechanistic biomarkers in inflammatory pain has provided the pharmacological basis for dose selection and evaluation of non-steroidal anti-inflammatory drugs (NSAIDs).

CONCLUSION

A different paradigm is required for the identification of relevant targets and candidate molecules whereby pain is coupled to the cause of sensorial signal processing dysfunction rather than clinical symptoms. Biomarkers which enable the characterisation of drug binding and target activity are needed for a more robust dose rationale in early clinical development. Such an approach may be facilitated by quantitative clinical pharmacology and evolving technologies in brain imaging, allowing accurate assessment of target engagement, and prediction of treatment effects before embarking on large clinical trials.

TDAG8, TRPV1, and ASIC3 involved in establishing hyperalgesic priming in experimental rheumatoid arthritis

Rheumatoid arthritis (RA), characterized by chronic inflammation of synovial joints, is often associated with ongoing pain and increased pain sensitivity. High hydrogen ion concentration (acidosis) found in synovial fluid in RA patients is associated with disease severity. Acidosis signaling acting on proton-sensing receptors may contribute to inflammation and pain. Previous studies focused on the early phase of arthritis (<5 weeks) and used different arthritis models, so elucidating the roles of different proton-sensing receptors in the chronic phase of arthritis is difficult. We intra-articularly injected complete Freund’s adjuvant into mice once a week for 4 weeks to establish chronic RA pain. Mice with knockout of acid-sensing ion channel 3 (ASIC3) or transient receptor potential/vanilloid receptor subtype 1 (TRPV1) showed attenuated chronic phase (>6 weeks) of RA pain. Mice with T-cell death-associated gene 8 (TDAG8) knockout showed attenuated acute and chronic phases of RA pain. TDAG8 likely participates in the initiation of RA pain, but all three genes, TDAG8, TRPV1, and ASIC3, are essential to establish hyperalgesic priming to regulate the chronic phase of RA pain.

Protocol for a randomised crossover trial to evaluate patient and nurse satisfaction with electronic and elastomeric portable infusion pumps for the continuous administration of antibiotic therapy in the home: the Comparing Home Infusion Devices (CHID) study

INTRODUCTION

Previous studies comparing satisfaction with electronic and elastomeric infusion pumps are limited, and improvements in size and usability of electronic pumps have since occurred. The Comparing Home Infusion Devices (CHID) study plans to assess patient and nurse satisfaction with an elastomeric and electronic pump for delivering intravenous antibiotic treatment in the home. Secondary objectives are to determine pump-related complications and actual antibiotic dose administered, evaluate temperature variation and compare pump operating costs.

METHODS AND ANALYSIS

The CHID study will be a randomised, crossover trial. A trained research nurse will recruit patients with infectious disease aged ≥18 years and prescribed ≥8 days of continuous intravenous antibiotic therapy from the Royal Adelaide Hospital (RAH) (Adelaide, Australia). Patients will be randomised to receive treatment at home via an elastomeric (Baxter Infusor) or an electronic (ambIT Continuous) infusion pump for 4-7 days, followed by the other for a further 4-7 days. Patient satisfaction will be assessed by a 10-item survey to be completed at the end of each arm. Nurse satisfaction will be assessed by a single 24-item survey. Patient logbooks and case notes from clinic visits will be screened to identify complications. Pumps/infusion bags will be weighed to estimate the volume of solution delivered. Temperature sensors will record skin and ambient temperatures during storage and use of the pumps throughout the infusion period. Costs relating to pumps, consumables, antibiotics and servicing will be determined. Descriptive statistics will summarise study data.

ETHICS AND DISSEMINATION

This study has been approved by the RAH Human Research Ethics Committee (HREC/16/RAH/133 R20160420, version 6.0, 5 September 2016). Study results will be disseminated through peer-reviewed publications and conference presentations. The CHID study will provide key insights into patient and provider satisfaction with elastomeric and electronic infusion pumps and inform future device selection.

TRIAL REGISTRATION NUMBER

ACTRN12617000251325; Pre-results.