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Al-Nasrawi AN, Al-Ibrahim MW, Aljabran SJ. Evaluating the Efficacy of Methocarbamol and Nefopam in Orthopedic Surgical Pain. Cureus 2024; 16:e59533. [PMID: 38707756 PMCID: PMC11066708 DOI: 10.7759/cureus.59533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction Pain after orthopedic surgeries represents a special concern in patients with fractures. The use of multimodal analgesia significantly reduced the opioid need and reduced the risk of their side effects. Objectives This study compared the effectiveness and safety of methocarbamol and nefopam in the reduction of post-operative pain for patients undergoing orthopedic surgeries. Method This prospective, double-blind, randomized controlled trial took place at Al-Sader Teaching Hospital in Basrah, Iraq, from the first of February 2022 to the end of October 2023. The study aimed to assess the post-operative pain relief efficacy and safety of intramuscular nefopam (20 mg) and intravenous methocarbamol (1 g) in 110 adults (aged 18-65) undergoing elective orthopedic surgeries. Exclusions were made for allergies to the drugs, substance abuse history, and severe hepatic or renal impairment. Participants were randomized into two groups, with pain intensity measured at one hour, six hours, and 12 hours post-operation using the visual analog scale (VAS). Side effects were also evaluated. Statistical analysis was done using SPSS 27, with a significance level set at p<0.05 and a 95% confidence interval (CI). Results In this study, we conducted a rigorous comparison between two groups, methocarbamol and nefopam, to evaluate their efficacy and safety in post-operative pain management. We started by ensuring that the groups were well-matched in terms of age, gender distribution, and body mass index (BMI). The results showed remarkable similarities in mean age, gender distribution, and BMI, supported by robust p-values, affirming the effective matching of the two groups. Moving to pain management, we observed a significant advantage in favor of methocarbamol. At all-time intervals (one hour, six hours, and 12 hours post-operation), methocarbamol consistently demonstrated lower mean VAS scores compared to nefopam. These differences were highly statistically significant, underscoring the superior pain relief efficacy of methocarbamol. Exploring side effects, we found no statistically significant disparities in the occurrence of nausea and vomiting between the two groups. However, there was a noticeable trend toward higher tachycardia incidence in the nefopam group, though it did not reach statistical significance. Conclusion The present study showed a higher efficacy of methocarbamol in post-operative pain reduction in comparison to nefopam. No serious side effects were observed with both drugs.
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Fallon F, Moorthy A, Skerritt C, Crowe GG, Buggy DJ. Latest Advances in Regional Anaesthesia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:735. [PMID: 38792918 PMCID: PMC11123025 DOI: 10.3390/medicina60050735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024]
Abstract
Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.
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Affiliation(s)
- Frances Fallon
- Department of Anaesthesia, Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland;
| | - Aneurin Moorthy
- Department of Anaesthesia, National Orthopaedic Hospital Cappagh/Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland; (A.M.)
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Conor Skerritt
- Department of Anaesthesia, National Orthopaedic Hospital Cappagh/Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland; (A.M.)
| | - Gillian G. Crowe
- Department of Anaesthesia, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
| | - Donal J. Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland;
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
- The ESA-IC Oncoanaesthesiology Research Group and Outcomes Research, Cleveland, OH 44195, USA
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Moser A, Wagner S, Habegger K, Cioccari L, Tosetti S. From the Operating Room to the Cave: Ultrasound-Guided Locoregional Anesthesia in the Setting of Cave Rescue-A Description of 2 Cases. Wilderness Environ Med 2023; 34:553-557. [PMID: 37741729 DOI: 10.1016/j.wem.2023.07.009] [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] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 09/25/2023]
Abstract
Caving accidents are rare, but when they occur, they represent a unique logistical and medical challenge. Retrieving the patient to the surface often means navigating stretchers through narrow corridors with limited options for monitoring and interventions. Because the patient is usually not fasting, opioids and sedatives should be used with extreme caution. Therefore, alternative analgesic techniques such as locoregional nerve blocks are a promising strategy to improve patient comfort and safety during cave rescues. In this article, we describe 2 cases in which portable point-of-care ultrasound equipment was used to supplement clinical assessment and provide locoregional anesthesia to facilitate patient evacuation and transport. In this context, we discuss the role of portable ultrasound-guided locoregional anesthesia in cave rescue and in the global preclinical context. In summary, our cases demonstrated that the administration of ultrasound-guided prehospital locoregional anesthesia is a safe, rapid, and effective procedure even in extreme situations such as cave rescues. The advent of portable, high-quality ultrasound equipment may open the door for more widespread application of this technique in the global preclinical setting.
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Affiliation(s)
- Alexandre Moser
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Swiss Cave Rescue Organization (Spéléo-Secours Suisse), La Chaux-de-Fonds, Switzerland; Swiss Alpine Rescue, Zürich Airport, Zürich, Switzerland; Air Glaciers SA, Sion, Switzerland
| | - Sarah Wagner
- Swiss Cave Rescue Organization (Spéléo-Secours Suisse), La Chaux-de-Fonds, Switzerland; Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Katrin Habegger
- Swiss Cave Rescue Organization (Spéléo-Secours Suisse), La Chaux-de-Fonds, Switzerland; Department of Emergency Medicine, Spital Thun, Thun, Switzerland; Department of Intensive Care Medicine, Spital Thun, Thun, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sylvain Tosetti
- Swiss Cave Rescue Organization (Spéléo-Secours Suisse), La Chaux-de-Fonds, Switzerland; Department of Anesthesiology and Perioperative Medicine, Hospital of Valais, Sion, Switzerland; Mobile Anesthesia Care, Bulle, Switzerland.
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Marrone F, Graziano G, Paventi S, Tomei M, Gucciardino P, Bosco M. Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:501-508. [PMID: 37678449 DOI: 10.1016/j.redare.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 10/26/2022] [Indexed: 09/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Data on the efficacy of PENG (Pericapsular Nerve Group) block in hip trauma pain are scarce. We hypothesized that PENG block was more effective than infra-inguinal ultrasound-guided FIB (Fascia Iliaca block) for pain control in patients aged 65 years or older presenting in the emergency room (ER) with traumatic proximal femoral fracture. MATERIALS AND METHODS We conducted an exploratory, double-blind, randomized controlled trial. One anaesthesiologist performed the block and another assessed outcomes. Patients were randomly allocated to the PENG group (20 ml ropivacaine 0.375%) or the infrainguinal FIB group (40 ml ropivacaine 0.2%). Standard hypothesis tests (t test or χ2 test) were performed to analyse baseline characteristics and outcome parameters. The primary end-point of the study was analgesic success, defined as "NRS pain score ≤ 4" 30 min after blockade, with PENG vs to FIB. Secondary outcomes were pain at rest ("pain at rest NRS score ≤ 4" 30 min after blockade), duration of analgesia (time to first request for analgesia), need for rescue medication in case of block failure, and complications during blockade. RESULTS After obtaining ethical committee approval and written informed consent, 60 patients were included. The primary endpoint was achieved in 16 out of 30 patients (53.3%) in the PENG group and in 15 out of 28 patients (53.6%) in the FIB group. Comparison between groups did not show superiority of the PENG vs FIB (P-value .98). CONCLUSIONS PENG block does not provide better pain than FIB in proximal femoral fracture in elderly patients treated in the ER.
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Affiliation(s)
- F Marrone
- ASL Roma 1, Santo Spirito Hospital, Roma, Italy.
| | - G Graziano
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
| | - S Paventi
- ASL Roma 1, Santo Spirito Hospital, Roma, Italy
| | - M Tomei
- ASL Roma 1, Santo Spirito Hospital, Roma, Italy
| | | | - M Bosco
- ASL Roma 1, Santo Spirito Hospital, Roma, Italy
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Regional anesthesia and analgesia for trauma: an updated review. Curr Opin Anaesthesiol 2022; 35:613-620. [PMID: 36044292 DOI: 10.1097/aco.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain. RECENT FINDINGS In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes. SUMMARY Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
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Perlman R, Lo J, Po J, Baldini G, Amir A, Zhang V. Trauma and the Anesthesiologist: an International Perspective. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hazrati E, Afsahi M, Namazi M, Kheradmand B, Rafiei M. Effect on analgesia duration and pain intensity of adding dexamethasone to lidocaine in digital nerve block in patients with finger trauma. HAND SURGERY & REHABILITATION 2021; 40:794-798. [PMID: 34438110 DOI: 10.1016/j.hansur.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/20/2021] [Accepted: 08/06/2021] [Indexed: 11/19/2022]
Abstract
Digital nerve block is one of the multimodal analgesia methods used in finger trauma cases. According to some studies, dexamethasone needs further investigation before being used routinely. We therefore investigated dexamethasone's effect on the parameters of digital nerve block. In this double-blind clinical study, 60 patients were allocated to two groups: lidocaine alone and lidocaine + dexamethasone. Groups were compared for pain intensity, analgesia duration and demographic characteristics. Patients in the intervention group received 3 cc 2% lidocaine + 1 cc (equivalent to 4 mg) dexamethasone and patients in the control group received 3 cc lidocaine 2% + 1 cc normal saline. The two groups were comparable for age and gender. In the lidocaine + dexamethasone group, postoperative pain severity was significantly lower and the pain-free period was longer (P < 0.05). Dexamethasone as an adjuvant in digital nerve block after trauma reduced the severity of postoperative pain and increased the pain-free period.
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Affiliation(s)
- E Hazrati
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Afsahi
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Namazi
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - B Kheradmand
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran
| | - M Rafiei
- Department of Anesthesiology, School of Medicine, Surgical and Trauma Research Center, Third Floor of Emam Reza Hospital, AJA University of Medical Sciences, West Fatemi St. - Etemadzadeh St., 8158177365 Isfahan, Isfahan Province, Dolatabad, Iran.
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DeYoung HR, Hughey SB, Miller GA, Cole JH, Longwell JJ. Regional Anesthesia for Symptomatic Treatment of Stingray Envenomation. Wilderness Environ Med 2021; 32:508-510. [PMID: 34419368 DOI: 10.1016/j.wem.2021.06.001] [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: 07/27/2020] [Revised: 04/19/2021] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Stingray envenomation is common in coastal regions around the world and may result in intense pain that can be challenging to manage. Described therapies involve hot water immersion and potentially other options such as opioid and nonopioid analgesics, removal of the foreign body, wound debridement, antibiotics for secondary infection, and tetanus toxoid. However, for some patients, this may not be enough. Peripheral nerve blockade is a frequently used perioperative analgesic technique, but it has rarely been described in the management of stingray envenomation. Here, we report a case of stingray envenomation in an otherwise healthy 36-y-old male with pain refractory to traditional therapies. After admission for pain control, the patient received an ultrasound-guided sciatic popliteal nerve block. Upon completion of the peripheral nerve block, the patient reported rapid and complete resolution of the intense pain, which did not return thereafter.
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Affiliation(s)
- Henry R DeYoung
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia.
| | - Scott B Hughey
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia; Naval Experimental Physiology Technology Unit for New and Emerging (NEPTUNE) Biotechnologies, Portsmouth, Virginia
| | - Grant A Miller
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia
| | - Jacob H Cole
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia; Naval Experimental Physiology Technology Unit for New and Emerging (NEPTUNE) Biotechnologies, Portsmouth, Virginia
| | - Jason J Longwell
- Naval Medical Center Portsmouth Department of Anesthesiology, Portsmouth, Virginia
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9
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Nathanson MH, Harrop-Griffiths W, Aldington DJ, Forward D, Mannion S, Kinnear-Mellor RGM, Miller KL, Ratnayake B, Wiles MD, Wolmarans MR. Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists. Anaesthesia 2021; 76:1518-1525. [PMID: 34096035 PMCID: PMC9292897 DOI: 10.1111/anae.15504] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 11/30/2022]
Abstract
Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.
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Affiliation(s)
- M H Nathanson
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, President, Association of Anaesthetists (Co-Chair), Nottingham, UK
| | - W Harrop-Griffiths
- Imperial College, Vice President, Royal College of Anaesthetists (Co-Chair), London, UK
| | - D J Aldington
- Hampshire Hospitals NHS Trust, British Pain Society, Hampshire, UK
| | - D Forward
- Department of Trauma and Orthopaedic Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Mannion
- Department of Anaesthesiology, South Infirmary Victoria University Hospital, Irish Standing Committee, Association of Anaesthetists, Cork, Ireland
| | - R G M Kinnear-Mellor
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Surgeon Commander, Royal Navy; Chair, Defence Medical Services Military Pain Special Interest Group, Nottingham, UK
| | - K L Miller
- Department of Paediatric Anaesthesia, Birmingham Women's and Children's NHS Foundation Trust, Trainee Committee, Association of Anaesthetists, Birmingham, UK
| | - B Ratnayake
- Department of Anaesthesia, Kingston Hospital NHS Trust, Immediate Past President, British Society of Orthopaedic Anaesthetists, Immediate Past President, British Society of Orthopaedic Anaesthetists, Kingston-upon-Thames, UK
| | - M D Wiles
- Department of Anaesthesia and Operating Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M R Wolmarans
- Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Past-President, Regional Anaesthesia UK (RA-UK), Norwich, UK
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George S, Johns M. Review of nonopioid multimodal analgesia for surgical and trauma patients. Am J Health Syst Pharm 2020; 77:2052-2063. [DOI: 10.1093/ajhp/zxaa301] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AbstractPurposePain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.SummaryIn response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.ConclusionMultimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.
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Affiliation(s)
- Stephy George
- Department of Pharmacy, Texas Health Harris Methodist Hospital, Fort Worth, TX
| | - Meagan Johns
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, TX
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Kolstadbraaten KM, Spreng UJ, Wisloeff‐Aase K, Gaarder C, Naess PA, Raeder J. Incidence of chronic pain 6 y after major trauma. Acta Anaesthesiol Scand 2019; 63:1074-1078. [PMID: 31012096 DOI: 10.1111/aas.13380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Life saving measures is the main focus in the initial treatment of major trauma. In surviving patients, chronic pain may be a serious problem, but the long term incidence and potential risk factors are not very well studied. METHODS All adult trauma patients included in the institutional trauma registry in 2007 were assessed for eligibility. Among exclusion criteria were: Injury Severity Score < 9, endotracheal intubation before or during admission, spinal cord lesion, known chronic drug or substance abuse, major surgery within 3 h after admission. A patient questionnaire was sent out 6 y after injury focusing on frequency and intensity of pain. A subgroup analysis was done in patients with thoracic injuries, comparing patients with epidural analgesia (EDA) and patients without. RESULTS Sixty-eight patients were included in the study. Sixty-nine percent reported pain 6 y after injury and 24% had severe pain. The severity of the injury was a risk factor for development of chronic pain, whereas pain during initial hospital stay was not. In patients with thoracic injuries there was no correlation between initial treatment with EDA and decreased incidence of chronic pain, however patient numbers were small. Opioids were the main analgesics used initially; no patients received non-steroidal anti-inflammatory drugs or peripheral nerve blocks during the first 24 h. CONCLUSION Two thirds of the trauma patients had chronic pain 6 y after injury and one out of four had severe pain. The initial pain treatment was focused on opioids.
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Affiliation(s)
| | | | - Kristin Wisloeff‐Aase
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Christine Gaarder
- Department of Traumatology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Paal Aksel Naess
- Department of Traumatology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Johan Raeder
- Department of Anaesthesiology Oslo University Hospital Oslo Norway
- Faculty of Medicine, Institute of Clinical Medicine University of Oslo Oslo Norway
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Maignan M, Termoz-Masson N, Viglino D. Retour d’expérience sur l’utilisation du méthoxyflurane aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’oligoanalgésie chez le patient traumatisé aux urgences est une situation fréquente du fait de la complexité de la prise en charge de la douleur. L’une des solutions les mieux décrites à ce problème est l’utilisation d’analgésiques dès l’admission du patient. Ce type de protocole est à privilégier notamment en cas de filière de prise en charge rapide au sein des urgences. Le méthoxyflurane est un éther halogéné volatil utilisé en médecine. Son inhalation produit une analgésie supérieure au placebo. Du fait de sa rapidité d’action, de sa facilité d’emploi et de ses propriétés antalgiques, le méthoxyflurane doit faire partie de l’arsenal des thérapeutiques antalgiques aux urgences. Aux urgences du CHU de Grenoble-Alpes, nous privilégions l’utilisation du méthoxyflurane au sein d’un protocole d’analgésie multimodale du patient adulte traumatisé. Dans cette indication, le méthoxyflurane permet d’amorcer l’analgésie et de faire le pont jusqu’à ce que les autres thérapeutiques soient efficaces.
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Büttner B, Mansur A, Kalmbach M, Hinz J, Volk T, Szalai K, Roessler M, Bergmann I. Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial. PLoS One 2018; 13:e0199776. [PMID: 29965991 PMCID: PMC6028078 DOI: 10.1371/journal.pone.0199776] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/08/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS. METHODS Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10). RESULTS Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01). CONCLUSIONS Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.
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Affiliation(s)
- Benedikt Büttner
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
| | - Ashham Mansur
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
| | - Matthias Kalmbach
- Department of Anesthesiology and Intensive Care Medicine, Hospital of Fulda, University Medical Center of Marburg, Fulda, Germany
| | - José Hinz
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Medical Centre, Saarland University, Homburg (Saar), Germany
| | - Karoly Szalai
- Department of Trauma, Spine Surgery and Orthopedics, Evangelical Hospital Mülheim, Mülheim (an der Ruhr), Germany
| | - Markus Roessler
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
| | - Ingo Bergmann
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center, University of Goettingen, Goettingen, Germany
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Sullivan D, Lyons M, Montgomery R, Quinlan-Colwell A. Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective. J Trauma Nurs 2017; 23:361-375. [PMID: 27828892 PMCID: PMC5123624 DOI: 10.1097/jtn.0000000000000250] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.
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Affiliation(s)
- Denise Sullivan
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Mary Lyons
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Robert Montgomery
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
| | - Ann Quinlan-Colwell
- Anesthesiology/Pain Management Service, Jacobi Medical Center, Bronx, New York (Ms Sullivan); Inpatient Pain Management, Northwestern Medicine-Central DuPage Hospital, Winfield, Illinois (Ms Lyons); Anesthesiology, University of Colorado Hospital, Aurora, Colorado (Dr Montgomery); and Clinical Outcomes, New Hanover Regional Medical Center, Wilmington, North Carolina (Dr Quinlan-Colwell)
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Driscoll EBS, Maleki AH, Jahromi L, Hermecz BN, Nelson LE, Vetter IL, Evenhuis S, Riesenberg LA. Regional anesthesia or patient-controlled analgesia and compartment syndrome in orthopedic surgical procedures: a systematic review. Local Reg Anesth 2016; 9:65-81. [PMID: 27785097 PMCID: PMC5063486 DOI: 10.2147/lra.s109659] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A systematic review of the literature on the use of regional anesthesia (RA) and patient-controlled analgesia (PCA) was conducted in patients who require orthopedic extremity procedures to determine whether either analgesic technique contributes to a delayed diagnosis of compartment syndrome (CS). A total of 34 relevant articles (28 case reports and six research articles) were identified. Of all case report articles published after 2009, the majority (75%) concluded that RA does not put the patient at an increased risk of a delayed diagnosis of CS. Of these, only two relevant prospective research studies focusing on RA or PCA and their relationship to CS were identified. Neither study resulted in any cases of CS. However, both had relatively small sample sizes. Given the lack of evidence identified in this systematic review, prospective studies or large-scale retrospective data reviews are needed to more strongly advocate the use of one modality of analgesia over the other in this patient population.
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Affiliation(s)
| | - Ana Hosseinzadeh Maleki
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Leila Jahromi
- Department of Biology, Georgia State University, Atlanta, GA
| | - Brittany Nelson Hermecz
- Department of Diagnostic Radiology, University of Alabama at Birmingham School of Medicine, Birmingham
| | | | - Imelda L Vetter
- School of Health Professions, Lister Hill Library, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Spencer Evenhuis
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Lee Ann Riesenberg
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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Bashir K, Pervaiz MA, Shehata OMA, Khan S. Regional blocks for the management of acute traumatic pain in the emergency department. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2016. [DOI: 10.5339/jemtac.2016.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Regional blocks provide adequate analgesia in trauma patients. The aim of this study was to review the current practice of emergency department physicians in the use of regional blocks.
A cross-sectional survey was conducted among emergency department physicians and anesthesiologists. The response rate was 100% (n = 107). 79% (n = 57) of the anesthesiologists were found to provide regional blocks however, 48.5% (n = 17) of emergency physicians administer local blocks. Only 2.8% of emergency physicians held a formal qualification in regional anesthesia.
There is a need to train ED physicians in regional blocks so that the pain in trauma patients can be managed early.
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Affiliation(s)
- Khalid Bashir
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Sibghatullah Khan
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth 2015; 8:45-55. [PMID: 26316813 PMCID: PMC4540140 DOI: 10.2147/lra.s55322] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Trauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.
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Affiliation(s)
- Jeff Gadsden
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Alicia Warlick
- Department of Anesthesiology, Duke University, Durham, NC, USA
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Yoshida H, Yaguchi S, Matsumoto A, Hanada H, Niwa H, Kitayama M. A modified paravertebral block to reduce risk of mortality in a patient with multiple rib fractures. Am J Emerg Med 2014; 33:735.e3-4. [PMID: 25456336 DOI: 10.1016/j.ajem.2014.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 10/15/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Hitoshi Yoshida
- Department of Emergency and Disaster Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan.
| | - Shinya Yaguchi
- Department of Emergency and Disaster Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Atsufumi Matsumoto
- Department of Endocrinology and Metabolism, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hidetomo Niwa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masatou Kitayama
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Li J, Halaszynski TM. Regional anesthesia for acute pain management in elderly patients. World J Anesthesiol 2014; 3:82-95. [DOI: 10.5313/wja.v3.i1.82] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/24/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Normal aging is a process that involves loss of functional reserve of most organ systems of the human body, most significantly: cardiovascular, pulmonary, renal and nervous systems. Advancements in both surgery and anesthesia have made it possible to operate more safely on the elderly population and those older patients with multiple severe co-morbidities that were not routinely possible in the recent past. Regional anesthesiologist have proven to be instrumental in this regard as regional anesthetic/analgesic techniques may now permit surgeons to operate on the elderly who were not ideal surgical candidates or unable to tolerate general anesthesia. In addition, regional techniques provide alternatives that may optimize acute pain control and reduce the incidence of devastating side effects during the perioperative period such as: myocardial infarction, pulmonary embolism, pneumonia, and also increases the opportunity to allow for early ambulation and shorter hospital stays. These anesthetic options now provide the elderly patient with better medical care alternatives, but also can show a significant financial impact on health care system resources. Further understanding on aging molecular biology, physiology and pathophysiology, together with technical improvements of regional anesthetic techniques will continue to make it safer and more efficacious to operate on the elderly population with evidence of reduced morbidity and mortality. Although there is only anecdotal evidence that regional anesthesia (RA) improves survival, there is little doubt that RA plays an important role in perioperative optimization of pain control and decreases pain management complications as well as a reduction in healthcare costs. Beyond traditional operating rooms, elderly patients may increasingly benefit from RA and acute pain management in Emergency Rooms, medical clinics and even within a patient’s home. Therefore, the focus of this review is directed toward geriatric patients and beneficial effects of RA on outcomes in the elderly.
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