Battlefield analgesia: a brief review of current trends and concepts in the treatment of pain in US military casualties from the conflicts in Iraq and Afghanistan

A scoping review of mechanisms of auricular acupuncture for treatment of pain

OBJECTIVES

Auricular acupuncture (AA) is becoming increasingly common in primary care clinics, emergency departments and peri-operatively for pain relief. Over the last decade, since the last comprehensive reviews were published, the literature has expanded. In this scoping review, we seek to document the efficacy of AA in treating both acute and chronic pain, describe the mechanism of action of AA in treating pain, and discuss how AA has been integrated into Western medicine to date.

METHODS

The authors performed a MEDLINE search inclusive of articles from 1966 to June 2023 including articles written in English identifying literature. We included human studies when more than 3 patients were included. Three hundred and fourteen unique articles were identified and 152 were selected by title screen. After abstract review, 117 were chosen for full-text review. Following full-text review, 33 articles were excluded and 21 added from references, totaling 105 articles included in our scoping review.

RESULTS

AA reduces pain severity in patients with both acute and chronic pain. The best studies in the acute settings have occurred in the peri-operative setting where sham AA is employed, multiple sessions of AA are given, and medication dosing is carefully monitored. In these cases, AA reduced pain and post-operative medications. In patients with chronic pain, multiple sessions of AA resulted not only in pain relief but also in improvements in function and disability. Literature suggests that AA works through multiple mechanisms with the most compelling data coupled to the autonomic nervous system and neuroendocrine system. Curriculums designed to teach AA and aid in implementation have been published.

CONCLUSION

AA is an accessible, effective means of pain relief. AA is relatively straightforward to learn, and protocols and curriculums exist to teach healthcare professionals this valuable skill. Overcoming implementation barriers, including patient education, are essential next steps.

Anesthesiology Fellowships in the Military Health System: An Education Analysis of the Supply and Demand

INTRODUCTION

Evidence indicates that desire for fellowship training is most influenced by personal interest, enhancement of career options, and a specific interest in an academic medicine career. The overall objective of this study is to evaluate anesthesiology fellowship interest and its potential impact on military retention and other outcomes. We hypothesized that current fellowship training accessibility is outpaced by the interest for fellowship training and that additional factors will be associated with the desire for fellowship training.

METHODS

This prospective cross-sectional survey study was approved as Exempt Research by the Brooke Army Medical Center Institutional Review Board in November 2020. Participants were eligible to complete the online voluntary survey if they were active duty anesthesiologists. Anonymous surveys were administered via the Research Electronic Data Capture System from December 2020 to January 2021. Aggregated data were evaluated using univariate statistics, bivariate analyses, and a generalized linear model.

RESULTS

Seventy-four percent of general anesthesiologists (those without fellowship training) were interested in pursuing future fellowship training versus 23% of subspecialist anesthesiologists (those currently in fellowship training or have completed fellowship training), odd ratio 9.71 (95% CI, 4.3-21.7). Of subspecialist anesthesiologists, 75% indicated serving in a nongraduate medical education (GME) leadership position (e.g., service/department chief), with 38% serving in a GME leadership position (e.g., program or associate program director). Almost half (46%) of subspecialist anesthesiologists reported being "extremely likely" to serve ≥20 years, versus 28% of general anesthesiologists.

CONCLUSIONS

There is a high demand among active duty anesthesiologists for fellowship training, which in turn, may improve military retention. The demand for fellowship training is outpaced by what the Services currently offer, including training in Trauma Anesthesiology. Leveraging this interest in subspecialty fellowship training, particularly when the skills align with combat casualty care-related requirements, would greatly benefit the Services.

Effects of ketamine analgesia on cardiorespiratory responses and survival to trauma and hemorrhage in rats

Ketamine is the recommended analgesic on the battlefield for soldiers with hemorrhage, despite a lack of supportive evidence from laboratory or clinical studies. Hence, this study determined the effects of ketamine analgesia on cardiorespiratory responses and survival to moderate (37% blood volume; n = 8/group) or severe hemorrhage (50% blood volume; n = 10/group) after trauma in rats. We used a conscious hemorrhage model with extremity trauma (fibular fracture + soft tissue injury) while measuring mean arterial pressure (MAP), heart rate (HR), and body temperature (T_b) by telemetry, and respiration rate (RR), minute volume (MV), and tidal volume (TV) via whole body plethysmography. Male rats received saline (S) or 5.0 mg/kg ketamine (K) (100 µL/100 g body wt) intra-arterially after trauma and hemorrhage. All rats survived 37% hemorrhage. For 50% hemorrhage, neither survival times [180 min (SD 78) vs. 209 min (SD 66)] nor percent survival (60% vs. 80%) differed between S- and K-treated rats. After 37% hemorrhage, K (compared with S) increased MAP and decreased T_b and MV. After 50% hemorrhage, K (compared with S) increased MAP but decreased HR and MV. K effects on cardiorespiratory function were time dependent, significant but modest, and transient at the analgesic dose given. K effects on T_b were also significant but modest and more prolonged. With the use of this rat model, our data support the use of K as an analgesic in injured, hypovolemic patients.NEW & NOTEWORTHY Ketamine administration at a dose shown to alleviate pain in nonhemorrhaged rats with extremity trauma had only modest and transient effects on multiple aspects of cardiorespiratory function after both moderate (37%) and severe (50%) traumatic hemorrhages. Such effects did not alter survival.

Prehospital Analgesia With Intranasal Ketamine (PAIN-K): A Randomized Double-Blind Trial in Adults

STUDY OBJECTIVE

We compare intranasal ketamine with intranasal placebo in providing pain reduction at 30 minutes when added to usual paramedic care with nitrous oxide.

METHODS

This was a randomized double-blind study of out-of-hospital patients with acute pain who reported a verbal numeric rating scale (VNRS) pain score greater than or equal to 5. Exclusion criteria were younger than 18 years, known ketamine intolerance, nontraumatic chest pain, altered mental status, pregnancy, and nasal occlusion. Patients received usual paramedic care and were randomized to receive either intranasal ketamine or intranasal saline solution at 0.75 mg/kg. The primary outcome was the proportion of patients with VNRS score reduction greater than or equal to 2 at 30 minutes. Secondary outcomes were pain reduction at 15 minutes, patient-reported comfort, satisfaction scores, nitrous oxide consumption, and incidence of adverse events.

RESULTS

One hundred twenty subjects were enrolled. Seventy-six percent of intranasal ketamine patients versus 41% of placebo patients reported a greater than or equal to 2-point VNRS reduction at 30 minutes (difference 35%; 95% confidence interval 17% to 51%). Median VNRS reduction at 15 minutes was 2.0 and 1.0 and at 30 minutes was 3.0 and 1.0 for ketamine and placebo, respectively. Improved comfort at 15 and 30 minutes was reported for 75% versus 57% and 61% versus 46% of ketamine and placebo patients, respectively. Sixty-two percent of patients (95% confidence interval 49% to 73%) versus 20% (95% confidence interval 12% to 32%) reported adverse events with ketamine and placebo, respectively. Adverse events were minor, with no patients requiring physical or medical intervention.

CONCLUSION

Added to nitrous oxide, intranasal ketamine provides clinically significant pain reduction and improved comfort compared with intranasal placebo, with more minor adverse events.

Comparing the analgesic effect of intranasal with intravenous ketamine in isolated orthopedic trauma: A randomized clinical trial

Objectives

Ketamine is commonly used in anesthetic and sedation before surgical procedures and acts as an analgesic in smaller doses. The aim of this study was to assess the effects of intranasal (IN) ketamine in patients with moderate to severe limb trauma (visual analog scale (VAS) > 60 mm).

Methods

In a triple-blind randomized controlled clinical trial; 154 patients with isolated orthopedic trauma and visual analog scale (VAS) ≥60 mm were included on the basis of inclusion and exclusion criteria. Patients were divided into two groups of ketamine-IN (0.4 mg/kg IN ketamine and an equal volume of placebo saline intravenously (IV)) and ketamine-IV (0.2 mg/kg ketamine IV with 0.5 ml saline IN) on the basis of balanced block randomization method. At 5, 10, 20, and 30 min, patients were assessed for VAS measurement and adverse events. Repeated measure ANOVA, independent t-test and chi square test were employed. The level of statistical significance was considered to be less than 0.05.

Results

Mean VAS in IN ketamine and IV group at minute 30 was 31.50 ± 13.40 and 29.35 ± 11.73, respectively. At minute 30, 31 patients (20.39%) required a low-dose of morphine as rescue analgesia (P = 0.427). The results showed that mean change score of VAS (difference of time 0 and time 30) in IN ketamine and IV ketamine VAS were 43.8 (95% confidence interval: 41.1–46.5) and 46.4 (95% confidence interval: 42.8–50.1) and there is no difference between two groups in case of score change of VAS (P = 0.245). Adverse events in nasal and intravenous ketamine in both groups were mild and transient.

Conclusion

IN ketamine is associated with few side effects and appropriate analgesic effects in isolated orthopedic trauma patients, and it may be used in cases where there is no need for venipuncture of peripheral vessels, especially in crowded EDs.

Special Considerations for the Treatment of Pain from Torture and War

Pain care for survivors of torture and of war shows similarities and marked differences. For both, pain can be complex with unfamiliar presentations and the pains hard to assign to known disorders. For many survivors, pain and associated disability are overshadowed by psychological distress, often by post-traumatic stress symptoms that can be frightening and isolating. Pain medicine in war can exemplify best techniques and organisation, reducing suffering, but many military veterans have persistent pain that undermines their readjustment. By contrast, survivors of torture rarely have any acute health care; their risk for developing chronic pain is high. Even when settled as refugees in a well-resourced country, their access to healthcare may be restricted. Recent evidence is reviewed that informs assessment and treatment of pain in both groups, with the broader context of psychological distress addressed at the end. Clinical and research implications are briefly outlined.

A Multicenter Evaluation of the Impact of Sex on Abdominal and Fracture Pain Care

BACKGROUND

Previous studies examining sex-based disparities in emergency department (ED) pain care have been limited to a single pain condition, a single study site, and lack rigorous control for confounders.

OBJECTIVE

A multicenter evaluation of the effect of sex on abdominal pain (AP) and fracture pain (FP) care outcomes.

RESEARCH DESIGN

A retrospective cohort review of ED visits at 5 US hospitals in January, April, July, and October 2009.

SUBJECTS

A total of 6931 patients with a final ED diagnosis of FP (n=1682) or AP (n=5249) were included.

MEASURES

The primary predictor was sex. The primary outcome was time to analgesic administration. Secondary outcomes included time to medication order, and the likelihood of receiving an analgesic and change in pain scores 360 minutes after triage: Multivariable models, clustered by study site, were conducted to adjust for race, age, comorbidities, initial pain score, ED crowding, and triage acuity.

RESULTS

On adjusted analyses, compared with men, women with AP waited longer for analgesic administration [AP women: 112 (65-187) minutes, men: 96 (52-167) minutes, P<0.001] and ordering [women: 84 (41-160) minutes, men: 71 (32-137) minutes, P<0.001], whereas women with FP did not (Administration: P=0.360; Order: P=0.133). Compared with men, women with AP were less likely to receive analgesics in the first 90 minutes (OR=0.766; 95% CI, 0.670-0.875; P<0.001), whereas women with FP were not (P=0.357).

DISCUSSION

In this multicenter study, we found that women experienced delays in analgesic administration for AP, but not for FP. Future research and interventions to decrease sex disparities in pain care should take type of pain into account.

Intranasal ketamine for analgesia in the emergency department: a prospective observational series

OBJECTIVES

The objective was to examine the feasibility, effectiveness, and adverse effect profile of intranasal ketamine for analgesia in emergency department (ED) patients.

METHODS

This was a prospective observational study examining a convenience sample of patients aged older than 6 years experiencing moderate or severe pain, defined as a visual analog scale (VAS) score of 50 mm or greater. Patients received 0.5 to 0.75 mg/kg intranasal ketamine. Pain scores were recorded on a standard 100-mm VAS by trained investigators at baseline, then every 5 minutes for 30 minutes, and then every 10 minutes for an additional 30 minutes. The primary outcome was the number and proportion of patients experiencing clinically significant reductions in VAS pain scores, defined as VAS reductions of 13 mm or more, within 30 minutes. Secondary outcomes included the median reduction in VAS, the median time required to achieve a 13 mm reduction in VAS, vital sign changes, and adverse events. Continuous data are reported with medians and interquartile ranges (IQRs). The Wilcoxon signed-ranks test was used to assess changes in VAS scores. Adverse effects are reported with proportions and 95% confidence intervals (CIs).

RESULTS

Forty patients were enrolled with a median age of 47 years (IQR = 36 to 57 years; range = 11 to 79 years) for primarily orthopedic injuries. A reduction in VAS of 13 mm or more within 30 minutes was achieved in 35 patients (88%). The median change in VAS at 30 minutes was 34 mm (44%). Median time required to achieve a 13 mm VAS reduction was 9.5 minutes (IQR = 5 to 13 minutes; range = 5 to 25 minutes). No serious adverse effects occurred. Minor adverse effects included dizziness (21 patients, 53%; 95% CI = 38% to 67%), feeling of unreality (14 patients, 35%; 95% CI = 22% to 50%), nausea (four patients, 10%; 95% CI = 4% to 23%), mood change (three patients, 8%; 95% CI = 3% to 20%), and changes in hearing (one patient, 3%; 95% CI = 0% to 13%). All adverse effects were transient and none required intervention. There were no changes in vital signs requiring clinical intervention.

CONCLUSIONS

Intranasal ketamine reduced VAS pain scores to a clinically significant degree in 88% of ED patients in this series. Adverse effects were minor and transient. Intranasal ketamine may have a role in the provision of effective, expeditious analgesia to ED patients.