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Jiang T, Ma C, Wang Z, Miao Y. A review of local anesthetic-induced heart toxicity using human induced pluripotent stem cell-derived cardiomyocytes. Mol Cell Probes 2024; 76:101965. [PMID: 38823509 DOI: 10.1016/j.mcp.2024.101965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/11/2024] [Accepted: 05/29/2024] [Indexed: 06/03/2024]
Abstract
Local anesthetic (LA) cardiotoxicity is one of the main health problems in anesthesiology and pain management. This study reviewed the reported LA-induced cardiac toxicity types, risk factors, management, and mechanisms, with attention to the use of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in heart toxicity research. Important scientific databases were searched to find relevant articles. We briefly assessed the reported cardiotoxic effects of different types of LA drugs, including ester- and amide-linked LA agents. Furthermore, cardiotoxic effects and clinical manifestations, strategies for preventing and managing LA-induced cardiotoxic effects, pharmacokinetics, pharmacodynamics, and sodium channel dynamics regarding individual variability and genetic influences were discussed in this review. The applications and importance of hiPSC-CMs cellular model for evaluating the cardiotoxic effects of LA drugs were discussed in detail. This review also explored hiPSC-CMs' potential in risk assessment, drug screening, and developing targeted therapies. The main mechanisms underlying LA-induced cardiotoxicity included perturbation in sodium channels, ROS production, and disorders in the immune system response due to the presence of LA drugs. Furthermore, drug-specific characteristics including pharmacokinetics and pharmacodynamics are important determinants after LA drug injection. In addition, individual patient factors such as age, comorbidities, and genetic variability emphasize the need for a personalized approach to mitigate risks and enhance patient safety. The strategies outlined for the prevention and management of LA cardiotoxicity underscore the importance of careful dosing, continuous monitoring, and the immediate availability of resuscitation equipment. This comprehensive review can be used to guide future investigations into better understanding LA cardiac toxicities and improving patient safety.
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Affiliation(s)
- Ting Jiang
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Chao Ma
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China
| | - Zitong Wang
- Health Science Center, Lanzhou University, Lanzhou, 730000, China
| | - Yi Miao
- Department of Anesthesiology, Xi'an Children's Hospital, Xi'an, 710002, China.
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Hays H. Emergency Medicine Case Study on Local Anesthetic Systemic Toxicity. Adv Emerg Nurs J 2024; 46:234-240. [PMID: 39094084 DOI: 10.1097/tme.0000000000000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The purpose of this case study on local anesthetic systemic toxicity (LAST), a potentially life-threatening complication of local anesthetic, is to ensure that emergency nurse practitioners (ENPs) are knowledgeable on this disease process. Local anesthetics are used frequently, often daily, by ENPs, as well as multiple other health care providers for various procedures. They should be knowledgeable of the steps to resuscitate a patient who may have severe LAST. This case study reviews the emergency management of LAST, including pharmacologic treatment, deviations from routine advanced resuscitative guidelines, and disposition of the patient upon successful resuscitation. Additionally, risk assessment and clinical manifestations will be discussed. After reviewing this case study, ENPs should be able to recognize the presentation of LAST and provide emergent management to reduce complications, comorbidities, and death.
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Affiliation(s)
- Haley Hays
- Author Affiliation: Western Division, University of Nebraska Medical Center College of Nursing, Scottsbluff, NE, United States; and Emergency Medicine, Aligned Providers of Wyoming, Kimball, NE, United States
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Ayad M, Lee M, Diz Ferre JL, Oliver LA, Ayad S. Acute Pain Management in a Multi-site Trauma Patient. Cureus 2024; 16:e61596. [PMID: 38962628 PMCID: PMC11221626 DOI: 10.7759/cureus.61596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/05/2024] Open
Abstract
Pain management is often difficult in the setting of multi-site trauma such as that caused by motor vehicle accidents (MVA), which is especially compounded in the setting of polysubstance abuse. This often results in patients with poor pain tolerance requiring escalating doses of opioid therapy, which creates a vicious cycle. The use of peripheral nerve blocks (PNB) has been shown to decrease overall opioid consumption and can be used effectively to manage postoperative pain in this patient population. Our case report aims to highlight the importance of PNBs as part of a multimodal approach to pain management in patients with polytrauma in the setting of polysubstance abuse.
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Affiliation(s)
- Michael Ayad
- Outcomes Research Consortium, Lake Erie College of Osteopathic Medicine, Cleveland, USA
| | - Malcolm Lee
- Outcomes Research Consortium, Ohio University Heritage College of Osteopathic Medicine, Cleveland, USA
| | | | - Lori Ann Oliver
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
| | - Sabry Ayad
- Outcomes Research, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
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Genc C, Tulgar S, Unal M, Genc AS, Kehribar L, Erdivanli B, Vermeylen K, Koksal E. The minimum effective concentration (MEC90) of bupivacaine for an ultrasound-guided suprainguinal fascia iliaca compartment block for analgesia in knee surgery: a dose-finding study. Korean J Anesthesiol 2024; 77:364-373. [PMID: 38480982 PMCID: PMC11150113 DOI: 10.4097/kja.23710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND In recent years, the suprainguinal fascia iliaca compartment block (SFICB) has become more common in clinical practice. This assessor-blinded dose-finding study aimed to determine the minimum effective concentration (MEC90, MEC95) of bupivacaine for a single-injection SFICB in patients undergoing arthroscopic anterior cruciate ligament repair. METHODS This prospective study was conducted at a tertiary hospital (postoperative recovery room and ward). The SFICB was performed as a postsurgical intervention after spinal anesthesia. Seventy patients were allocated using the biased-coin design up-and-down sequential method. The ultrasound-guided SFICB was performed using different bupivacaine concentrations, and standard multimodal analgesia was administered to all patients. Block success was defined as the absence of pain or presence of only tactile sensation during the pinprick test conducted on the anterior and lateral regions of the mid-thigh six hours postoperatively. RESULTS According to isotonic regression and bootstrap CIs, the MEC90 value of bupivacaine for a successful SFICB was 0.123% (95% CI [0.098, 0.191]) and the MEC95 value was 0.188% (95% CI [0.113, 0.223]). CONCLUSIONS Our study showed that the MEC90 and MEC95 values for bupivacaine administered via an SFICB for analgesia were 0.123% and 0.188%, respectively. One advantage of using lower concentrations of bupivacaine is the associated reduction in quadriceps weakness.
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Affiliation(s)
- Caner Genc
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Murat Unal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Ahmet Serhat Genc
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Lokman Kehribar
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Basar Erdivanli
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University Faculty of Medicine, Rize, Turkey
| | - Kris Vermeylen
- Department of Anesthesia, AZ Turnhout, Turnhout, Belgium
| | - Ersin Koksal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
- Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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5
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Gabrieli A, Barberi C, Compostella C, Azzolini M, Butturini A, Larger G, Boldo L, Paganini M, Levato R, Ventura A. Local Anesthetic Systemic Toxicity Joint Management in the Prehospital Environment: A Case Report. Air Med J 2024; 43:256-258. [PMID: 38821709 DOI: 10.1016/j.amj.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/19/2024] [Accepted: 01/26/2024] [Indexed: 06/02/2024]
Abstract
Local anesthetic systemic toxicity (LAST) is a potentially life-threatening complication that may occur after local anesthetic injection. After reaching the systemic circulation, cardiovascular and central nervous system derangements may appear, with potentially fatal complications if left untreated. The pillars for LAST treatment are advanced life support measures, airway and seizure management, and a 20% lipid emulsion intravenous administration. When occurring in the prehospital setting, LAST is difficult to recognize, mostly because of its features overlapping with other acute conditions. Prompt treatment is also challenging because lipid emulsion may not be routinely carried on emergency vehicles. This article reports a case of LAST occurring in a dental ambulatory located in a remote location within the Italian Alps in which effective communication among different components of the same regional health care system (dispatch center, prehospital teams, and hospital network) led to fast lipid emulsion retrieval en route and on-site toxicity resolution. This case can inspire future operational changes, such as antidote networks available to prehospital emergency medicine crews, avoiding unnecessary deployment of antidotes on ambulances or helicopters, which is difficult to preserve without increasing management costs. However, to be established, such a network would need protocols to facilitate antidote retrieval, training focused on toxidromes recognition, and improved communication skills among different professionals involved in prehospital emergency medicine.
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Affiliation(s)
- Alberto Gabrieli
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Caterina Barberi
- Emergency Department, S. Maria del Carmine Hospital, Rovereto, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Caterina Compostella
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Michela Azzolini
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Andrea Butturini
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Gabriele Larger
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Lara Boldo
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Matteo Paganini
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy.
| | - Roberta Levato
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
| | - Andrea Ventura
- Trentino Emergenza Emergency Medical Service, Trento Healthcare Trust, Trento Healthcare Trust (APSS), Trento, Italy
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6
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Denke NJ. Local Anesthetic Systemic Toxicity (LAST): More Common Than You Think. J Emerg Nurs 2024; 50:336-341. [PMID: 38705705 DOI: 10.1016/j.jen.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 05/07/2024]
Abstract
The number of anesthetic body procedures in the United States is rapidly increasing, with many being performed on an outpatient basis. These procedures are advertised as being safe, and many times the serious complications may not be discussed. Although local anesthetic systemic toxicity is a rare complication, it is associated with an increase in morbidity. The emergency department staff should be aware of the possibility of this rare complication, as well as the variety of resulting symptoms (from minor to severe), potential sequelae, and appropriate management for patients who have undergone an outpatient anesthetic body procedure. Multiple factors contribute to the development of local anesthetic systemic toxicity, resulting in life-threatening effects on the neurologic and cardiovascular systems. Also, the site of administration, along with the local anesthetic agent used, can impact the risk of the development of local anesthetic systemic toxicity. To minimize the risk and ensure the best possible outcome for these patients, emergency department staff must be highly aware of the mechanisms, risk factors, prevention, and management/treatment of local anesthetic systemic toxicity.
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Huaguo Y, Kang S, Hu L, Zhou H. Advancing pain management for extremity trauma: the evolution of ultrasound-guided nerve blocks for patients in the supine position in trauma centers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02523-w. [PMID: 38649528 DOI: 10.1007/s00068-024-02523-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Trauma, particularly extremity trauma, poses a considerable challenge in healthcare, especially among young adults. Given the severity of patient pain and the risks associated with excessive opioid use, managing acute pain in trauma centers is inherently complex. This study aims to investigate the application and benefits of ultrasound-guided nerve blocks for early pain management in patients with extremity trauma positioned supine. METHODS A comprehensive literature review was conducted to assess the effectiveness and advantages of ultrasound-guided peripheral nerve blocks in the acute pain management of extremity trauma patients in the supine position. Special emphasis was placed on evaluating the selection criteria, indications, contraindications, adverse reactions, and potential complications associated with these nerve block techniques. RESULTS Ultrasound-guided nerve blocks represent a safer and more precise option for managing pain in extremity trauma patients placed in the supine position. These techniques offer significant advantages in terms of reducing healthcare expenses, diminishing reliance on opioid medications, and mitigating opioid-related complications. Nonetheless, challenges may arise due to the necessity for patient cooperation during specific nerve block procedures. CONCLUSION Ultrasound-guided nerve blocks present a promising avenue for early pain management in extremity trauma patients positioned supinely. Their implementation can lead to improved patient outcomes by alleviating pain severity, reducing opioid consumption, and cutting down healthcare costs. Further research and clinical integration of these techniques is imperative to enhance pain management protocols in trauma centers.
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Affiliation(s)
- Yuefeng Huaguo
- Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing University, Huancheng Strasse 1518, Jiaxing City, 314000, China
- Key Laboratory of Basic Research and Clinical Transformation of Perioperative Precision Anesthesia, Jiaxing City, China
| | - Shuai Kang
- Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing University, Huancheng Strasse 1518, Jiaxing City, 314000, China
- Key Laboratory of Basic Research and Clinical Transformation of Perioperative Precision Anesthesia, Jiaxing City, China
| | - Li Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing University, Huancheng Strasse 1518, Jiaxing City, 314000, China.
- Key Laboratory of Basic Research and Clinical Transformation of Perioperative Precision Anesthesia, Jiaxing City, China.
| | - Hongmei Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Jiaxing University, Huancheng Strasse 1518, Jiaxing City, 314000, China.
- Key Laboratory of Basic Research and Clinical Transformation of Perioperative Precision Anesthesia, Jiaxing City, China.
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8
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Tirupathi S, Afnan L, Sachdev M. Perioperative Lignocaine Intravenous Infusion (PLIV) in Maxillofacial Surgeries: Risk and Safety Considerations and Management. J Maxillofac Oral Surg 2024; 23:448-449. [PMID: 38601221 PMCID: PMC11001802 DOI: 10.1007/s12663-023-02003-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 08/16/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Sunnypriyatham Tirupathi
- Department of Pediatric and Preventive Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra 411018 India
| | - Lamea Afnan
- Department of Public Health Dentistry, Coorg Institute of Dental Sciences, Virajpet, Karnataka 571218 India
| | - Muskaan Sachdev
- Department of Pediatric and Preventive Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra 411018 India
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9
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Goldsmith AJ, Brown J, Duggan NM, Finkelberg T, Jowkar N, Stegeman J, Riscinti M, Nagdev A, Amini R. Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates. Am J Emerg Med 2024; 78:112-119. [PMID: 38244244 DOI: 10.1016/j.ajem.2023.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time. METHODS We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends. RESULTS The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually. CONCLUSIONS All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.
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Affiliation(s)
- Andrew J Goldsmith
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Joseph Brown
- Department of Emergency Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Nicole M Duggan
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | - Nick Jowkar
- University of Vermont College of Medicine, Burlington, VT, USA.
| | - Joseph Stegeman
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Matthew Riscinti
- Department of Emergency Medicine, Denver Health, University of Colorado, Denver, CO, USA.
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Richard Amini
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Galust H, Seltzer JA, Hardin JR, Friedman NA, Salamat J, Clark RF, Harmon J. Adulterants present in the San Diego county fentanyl supply: a laboratory analysis of seized law enforcement samples. BMC Public Health 2024; 24:923. [PMID: 38553721 PMCID: PMC10981322 DOI: 10.1186/s12889-024-18459-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 03/26/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND The opioid overdose crisis is one of the worst public health crises ever to face the US and emerging evidence suggests its effects are compounded by the presence of drug adulterants. Here we report our efforts to characterize the adulterants present within the local fentanyl supply of San Diego County, obtained from undifferentiated drug samples seized by local law enforcement over the calendar year 2021. METHODS Thirty-two participating local law enforcement agencies across San Diego submitted 4838 unknown individual illicit drug samples (total of 312 kg) to the San Diego County Sheriff's Department Regional Crime Laboratory for identification. RESULTS Qualitative analysis of these samples via FTIR and GC-MS identified methamphetamine (38.7%), fentanyl (20.8%), diacetylmorphine (heroin) (10.2%), codeine (5.8%) and alprazolam (4.3%) as the most common illicit substances and the presence of 52 unique adulterants. The most common adulterants included 4-methylaminoantipyrine (4-MAAP) (10.9%), mannitol (9%), acetaminophen (8.5%), methamphetamine (4.2%), diacetylmorphine (heroin) (3.6%), tramadol (1.9%), and xylazine (1.7%). Several additional pharmacologically active adulterants and contaminants of interest were also identified. CONCLUSION This analysis is vital for public health use and harm reduction efforts at the level of the individual consumer. Continued direct surveillance of the drug supply is necessary for the detection of potentially harmful adulterants that may pose serious threats to the public.
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Affiliation(s)
- Henrik Galust
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA.
- VA San Diego Healthcare System, San Diego, CA, USA.
- California Poison Control System, San Diego, CA, USA.
| | - Justin A Seltzer
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jeremy R Hardin
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Nathan A Friedman
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jeff Salamat
- San Diego County Sheriff's Crime Laboratory. John F. Duffy Administrative Center, 9621. Ridgehaven Ct, 92123, San Diego, CA, USA
| | - Richard F Clark
- Division of Medical Toxicology, Department of Emergency Medicine, UC San Diego Health, 200 W. Arbor Dr. #8676, 92103, San Diego, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
- California Poison Control System, San Diego, CA, USA
| | - Jennifer Harmon
- San Diego County Sheriff's Crime Laboratory. John F. Duffy Administrative Center, 9621. Ridgehaven Ct, 92123, San Diego, CA, USA
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Long B, Bridwell RE, Gottlieb M. Analgesic Techniques for Managing Orthopedic Injuries: A Review for the Emergency Clinician. J Emerg Med 2024; 66:211-220. [PMID: 38278679 DOI: 10.1016/j.jemermed.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/11/2023] [Accepted: 10/01/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Orthopedic injuries are commonly managed in the emergency department (ED) setting. Fractures and dislocations may require reduction for proper management. There are a variety of analgesic and sedative strategies to provide patient comfort during reduction. OBJECTIVE This narrative review evaluates hematoma block, intra-articular injection, intravenous regional analgesia (IVRA) (also known as the Bier block), and periosteal block for orthopedic analgesia in the ED setting. DISCUSSION Analgesia is an essential component of management of orthopedic injuries, particularly when reduction is necessary. Options in the ED setting include hematoma blocks, intra-articular injections, IVRA, and periosteal blocks, which provide adequate analgesia without procedural sedation or opioid administration. When used in isolation, these analgesic techniques decrease complications from sedation and the need for other medications, such as opioids, while decreasing ED length of stay. Emergency clinicians can also use these techniques as analgesic adjuncts. However, training in these techniques is recommended prior to routine use, particularly with IVRA. CONCLUSIONS Knowledge of analgesic techniques for orthopedic procedures can assist clinicians in optimizing patient care.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, Texas
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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Ma H, Pan Z, Lai B, Zan C, Liu H. Recent Research Advances in Nano-Based Drug Delivery Systems for Local Anesthetics. Drug Des Devel Ther 2023; 17:2639-2655. [PMID: 37667787 PMCID: PMC10475288 DOI: 10.2147/dddt.s417051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023] Open
Abstract
From a clinical perspective, local anesthetics have rather widespread application in regional blockade for surgery, postoperative analgesia, acute/chronic pain control, and even cancer treatments. However, a number of disadvantages are associated with traditional local anesthetic agents as well as routine drug delivery administration ways, such as neurotoxicity, short half-time, and non-sustained release, thereby limiting their application in clinical practice. Successful characterization of drug delivery systems (DDSs) for individual local anesthetic agents can support to achieve more efficient drug release and prolonged duration of action with reduced systemic toxicity. Different types of DDSs involving various carriers have been examined, including micromaterials, nanomaterials, and cyclodextrin. Among them, nanotechnology-based delivery approaches have significantly developed in the last decade due to the low systemic toxicity and the greater efficacy of non-conventional local anesthetics. Multiple nanosized materials, including polymeric, lipid (solid lipid nanoparticles, nanostructured lipid carriers, and nanoemulsions), metallic, inorganic non-metallic, and hybrid nanoparticles, offer a safe, localized, and long-acting solution for pain management and tumor therapy. This review provides a brief synopsis of different nano-based DDSs for local anesthetics with variable sizes and structural morphology, such as nanocapsules and nanospheres. Recent original research utilizing nanotechnology-based delivery systems is particularly discussed, and the progress and strengths of these DDSs are highlighted. A specific focus of this review is the comparison of various nano-based DDSs for local anesthetics, which can offer additional indications for their further improvement. All in all, nano-based DDSs with unique advantages provide a novel direction for the development of safer and more effective local anesthetic formulations.
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Affiliation(s)
- He Ma
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Zhenxiang Pan
- Department of Anesthesiology, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Bingjie Lai
- Department of Intensive Care Unit, The Second Hospital of Jilin University, Changchun, People’s Republic of China
| | - Chunfang Zan
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, People’s Republic of China
- Collaborative Innovation Center for Molecular Imaging of Precision Medicine, Shanxi Medical University, Taiyuan, People’s Republic of China
| | - He Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, People’s Republic of China
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Alkhouli M, Al-Nerabieah Z, Dashash M. A Novel Scale to Assess Parental Satisfaction of Dental Local Anesthetic Techniques in Children: A Cross-Sectional Study. Pain Res Manag 2023; 2023:9973749. [PMID: 37251688 PMCID: PMC10219770 DOI: 10.1155/2023/9973749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/31/2023]
Abstract
Background Pain control is one of the most important aspects that can affect parental satisfaction of the dental care provided for children. Dental local anesthesia has the highest impact on pain sensation of the children. However, there is no scale in the literature to assess parental satisfaction of dental local anesthetic techniques. Objectives This study was aimed to assess the parental satisfaction with dental local anesthetic techniques for their children through designing a scale that reflects satisfaction and to study the validity and reliability of this scale. Methods A cross-sectional observational study was conducted on 150 parents (102 mothers and 48 fathers). Two techniques of local anesthesia were used for each child participated in this study (inferior alveolar nerve block and computerized intraosseous anesthesia). The developed scale consisted of 20 items in a 5-point Likert scale. Half of the items were written in a negative format. Internal consistency, validity, and factor analysis were performed in this study. Independent t-test was used to compare between the two techniques of anesthesia, between boys and girls and among fathers and mothers. Results Parental satisfaction mean values were higher in the computerized intraosseous anesthesia group in comparison to inferior alveolar nerve block (P value <0.05). The T-test showed that there was no difference between boys and girls regarding parental satisfaction (P value >0.05). Furthermore, fathers show lower satisfaction in the computerized interosseous anesthesia group (P value <0.05). Excellent internal consistency of this scale was resulted as Cronbach's alpha reliability coefficient was 0.985. After factor analysis, seven factor components were retained by using varimax rotation. Conclusions Findings of this study reported that the designed parental satisfaction of dental local anesthetic techniques scale (PSLAS) is a valid and reliable scale to be used. Moreover, this study showed that parental satisfaction was higher when computerized intraosseous anesthesia was used in comparison to inferior alveolar nerve block.
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Affiliation(s)
- Muaaz Alkhouli
- Pediatric Dentistry, Faculty of Dentistry, Damascus University, Damascus, Syria
| | - Zuhair Al-Nerabieah
- Pediatric Dentistry, Faculty of Dentistry, Damascus University, Damascus, Syria
| | - Mayssoon Dashash
- Pediatric Dentistry, Faculty of Dentistry, Damascus University, Damascus, Syria
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Mohanty CR, Varghese JJ, Panda R, Sahoo S, Mishra TS, Radhakrishnan RV, Topno N, Hansda U, Shaji IM, Behera SHP. Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries. Am J Emerg Med 2023; 63:94-101. [PMID: 36332503 DOI: 10.1016/j.ajem.2022.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/19/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022] Open
Abstract
STUDY OBJECTIVE To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED). METHODS This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm. RESULTS A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group. CONCLUSION The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.
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Affiliation(s)
- Chitta Ranjan Mohanty
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
| | - Jithin Jacob Varghese
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ritesh Panda
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sangeeta Sahoo
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | | | | | - Nitish Topno
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Upendra Hansda
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ijas Muhammed Shaji
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Shri Hari Priya Behera
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India; Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Mohanty CR, Radhakrishnan RV, Singh N, Shaji IM. Re: Why ethyl chloride spray in arterial blood gas sampling? Am J Emerg Med 2022; 62:113-114. [PMID: 35995647 DOI: 10.1016/j.ajem.2022.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Chitta Ranjan Mohanty
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
| | | | - Neha Singh
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Ijas Muhammed Shaji
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Phlegmasia cerulea dolens causing compartment syndrome. Am J Emerg Med 2022; 61:234.e1-234.e3. [PMID: 35961832 DOI: 10.1016/j.ajem.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Phlegmasia cerulea dolens (PCD) is a rare condition characterized by a severely swollen, cyanotic, blue extremity due to a large proximal (iliofemoral) deep venous thrombosis extending into the collateral veins. Mortality in PCD ranges 20-40%. Due to severely compromised venous drainage, compartment pressures can rapidly increase 16-fold within 6 h, but rarely result in arterial compromise. CASE REPORT We present a case of a middle-aged woman with no prior history of deep venous thrombosis, with a blue swollen left leg in intractable severe pain unresponsive to 3 doses of hydromorphone. Her pain was successfully alleviated with IV Lidocaine. Patient was found to have phlegmasia cerulea dolens resulting in compartment syndrome of her left leg. Although the patient initially had no motor function, after catheter-directed thrombolysis and emergent thrombectomy, she regained her motor function and made a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Phlegmasia cerulea dolens complicated by severe compartment syndrome is a rare entity. Prompt recognition and treatment are necessary to prevent irreversible limb ischemia and associated morbidity and mortality. IV Lidocaine may be considered as an option for analgesia for such patients.
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Montrief T, Chavez S, Gottlieb M, Brady WJ, Long B. Further considerations regarding lipid emulsion for LAST. Am J Emerg Med 2022; 59:170-171. [PMID: 35868994 DOI: 10.1016/j.ajem.2022.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL, USA
| | - Summer Chavez
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, UT Health Houston, Houston, TX, USA
| | - William J Brady
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Brit Long
- Emergency Medicine, Brooke Army Medical Center, Fort Sam, Houston, TX, USA.
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Sohn JT. Lipid emulsion dosage used for resuscitation after drug toxicity. Am J Emerg Med 2022; 59:168-169. [PMID: 35868991 DOI: 10.1016/j.ajem.2022.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/13/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, 15 Jinju-daero 816 beon-gil, Jinju-si, Gyeongsangnam-do 52727, Republic of Korea; Institute of Health Sciences, Gyeongsang National University, Jinju-si 52727, Republic of Korea.
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