All Articles

Rachael W. Starcher¹, Craig R. Weinert¹, Kiersten Henry², Jeffery R. Dichter^1*

¹Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA

²MedStar Montgomery Medical Center, Olney, MD, USA

Intensive care units (ICU’s) are particularly susceptible to resource and personnel strain given the complexity and unpredictability of care. This featured prominently in the early course of the SARS-CoV-2 (COVID-19) pandemic, where poor patient outcomes were clearly linked to the increasing severity of ICU strain associated with decreased ICU capacity. Despite attempts at measuring ICU strain, there exists no operational model that ICU directors can implement to monitor strain or researchers can use to examine its effects.

This article reviews ICU strain indicators including census load (census, acuity, and admissions), ICU flow characteristics (admission/discharge criteria, sufficient staffing levels, and ICU performance), and consequence mediators (ICU queuing time and high-risk discharges) with attention to common themes and measures. Census load data suggests mortality risk is greater when ICU census starts higher, has high overall acuity, and with greater numbers of admissions especially when they arrive close together. Optimal ICU flow depends on maintaining a “strain mindset” when prioritizing patients, optimal ICU professional staffing, and maintaining high level ICU performance processes. Finally, delaying ICU admissions beyond six hours, or “after hours” or rushed ICU discharges result in increased mortality risk. Incorporating these ICU strain factors into an outcomes-focused model is proposed based on a conceptual framework with future research objectives recommended.

Swati Patel, Ashwini Reddy, Amiya Kumar Barik^*, Shiv Lal Soni, Narender Kaloria

Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Mandibulectomy most commonly performed as surgical management of oropharyngeal carcinoma leads to a wide array of anatomical and physiological changes which result in an anticipated difficult airway. There may be posterosuperior displacement of hyoid bone and tongue leading to reduction of retropalatal space along with loss of structural support to the tongue predisposing it to prolapse and development of obstructive sleep apnoea. Bulky flap reconstruction, limited mouth opening, and radiotherapy limiting neck mobility further compound the difficulty in airway management. This leads to a wide spectrum of issues ranging from difficulty in face mask ventilation to laryngoscopy and intubation. It is essential to individualize each case with a preformulated strategy outlining the primary and alternative approaches. A literature search was carried out using search engines like PubMed, Embase, Medline, and Google scholar using the terms “Difficult airway”, “Post-mandibulectomy”, “Difficult laryngoscopy, and Intubation”. The available literature was thoroughly reviewed by the authors before the final drafting of this article. A multidisciplinary team approach, thorough assessment, meticulous preparation, and critical decision-making are essential for successfully managing a difficult airway post-mandibulectomy.

Adrian G. Yabut, Joseph Evan Villaluz

Department of Anesthesiology, Kaweah Health Medical Center, Visalia, California, USA

Toshiyuki Kakinuma

Center for Human Reproduction, Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Japan

The World Health Organization (WHO) recommends using vacuum aspiration as a surgical treatment for spontaneous and surgical abortion in early pregnancy. They also state that dilatation and curettage (D & C) should be avoided from the perspective of safety and effectiveness and to prevent the risk of endometrial injury as it can cause thinning of the endometrium and Asherman syndrome. Maintaining a good endometrial environment is important for improving the chance of pregnancy. Manual vacuum aspiration (MVA) was developed in the 1970s. For spontaneous abortion in the first trimester, MVA reduces the risk of endometrial injury, leading to less intra- and postoperative pain and simplification of anesthesia during surgical treatment for spontaneous abortion. The WHO recommends administering standard pain relief during surgical treatment for medication-induced and spontaneous abortion but does not recommend using routine general anesthesia during MVA and D & C procedures. At our hospital, we perform MVA alone under local anesthesia using a paracervical block for the surgical treatment for spontaneous abortion in early pregnancy, and the safety and effectiveness of this has been previously reported. Here, we will describe the pain management strategy used at our hospital for spontaneous abortion in early pregnancy using MVA.

Alfredo Chiurazzi, Andrea Francioni, Neri Demarcus, Carlo V. Bellieni^*

Department of Pediatrics, University of Siena, Siena, Italy

Introduction: Pain is a major problem in clinical management of children. Pharmacological analgesia is the most commonly used analgesic treatment, but in some cases the use of non-pharmacological analgesic treatments (N-PAT) has been proposed.

Purpose: Our aims were to review the effectiveness and safety of N-PAT for pain relief in children, and to point out which are the most effective.

Material and Methods: We retrieved the clinical trials published in the years 2017-2022 in two databases: PubMed and Index Medicus, analyzing them with the PRISMA method. We used the following key-words: distraction, pain, child. Then we refined our search using in the same databases the key-words “pain” and “child”, matched with the terms that describe the N-PAT: “Virtual reality”, “Robot”, “Audiovisual distraction”, “Audio Distraction”, “Buzzy”, “Videogames”, “Parents verbal interactions”, “Distraction cards”, “Magic glove”, “Ipad”, “Picture book”, “Kaleidoscope”, “Soap bubbles” and “Hand massage”. Exclusion criteria were: reviews, case reports, papers in a language other than English, including patients other than children older than one month of age.

Results: We have screened 126 articles and 66 were excluded from the final pool. The most studied painful stimulation was needle procedures, where the most effective N-PAT was virtual reality, followed by the buzzy system. In the case of other painful procedures, few studies were available; however, in any of these painful stimulations effective analgesia was obtained with the use of virtual reality. Several studies eventually show that the combination of N-PAT with analgesic topic drugs provides more effective analgesia.

Conclusion: Some non-pharmacological treatments appear actually effective. The research in this field should be implemented to get more conclusive data, but our results are in favor of more extended use of N-PAT during potentially painful procedures.

Allan A. Abbass^1*, Joel M. Town¹, Steve Kisely²

¹Centre for Emotions and Health, Dalhousie University, Halifax, Canada

²Faculty of Medicine, The University of Queensland, Woolloongabba, QLD, Australia

Intensive short-term dynamic psychotherapy (ISTDP) has been studied for a broad range of somatic symptom presentations including chronic pain. Drawn from two recent meta-analyses, data using ISTDP treatment for pain conditions was extracted and meta-analyzed. Ten studies, including 6 randomized controlled trials, were examined. Short- and medium-term results were available and ISTDP yielded large and persistent treatment effects for both pain and depression within group. In the short-term follow-up, large within group effects were seen for measures of anxiety, and medium within group effects were seen on measures of interpersonal problems. When ISTDP was compared to cognitive behavioral therapy methods (CBT) in randomized controlled trials, it yielded superior effects to CBT on pain and depression measures in both short- and medium-term follow-up. There was evidence of heterogeneity which was reduced by removing 2 outlying studies, yet the results remained significant and of moderate to large effects. Two studies suggested the method was cost effective by reducing healthcare costs, medication and disability costs. Based on these findings ISTDP should be considered for chronic pain treatment guidelines. Future research directions are discussed.

Joana A. Almeida*, Andreia F. Sá, Ana M. Remelhe, Humberto S. Machado

Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Portugal

Background: Topical vasoconstrictors are commonly used to minimize bleeding during Ear, Nose and Throat surgeries. Phenylephrine is one of the most commonly used and could be an underrecognized source of intra-operative events. Total dose of administered drugs is often unmeasured.

Cases of acute pulmonary edema, cardiac arrest and death after topical vasoconstrictors (TV) have been reported. Maintenance of cardiac output is of paramount importance to avoid cardiovascular collapse. β1 receptor blockage reduces cardiac output, it is contraindicated in these situations.

Case: This case describes an intra-operative critical event after an unknown amount of phenylephrine administration.

Conclusion: Lack of awareness about phenylephrine maximum recommended dose may induce complications leading to haemodynamic instability. The authors aim to raise awareness about the use of TV, including dose, administration site and also clinical signs and symptoms that may appear after its use.  Special attention must be addressed to the drug choice for the support treatment of eventual cardiovascular symptoms.

Hilde M. Buiting^1,2,3,4*, Lisan Ravensbergen^4,5, Christa van Schaik⁶, Vincent K.Y. Ho⁷, Gabe S. Sonke^3,8

¹Antoni van Leeuwenhoek, Netherlands Cancer Institute, Amsterdam, the Netherlands

²University Medical Center, Utrecht, the Netherlands

³University of Amsterdam, Amsterdam, the Netherlands

⁴O2PZ, Platform of Palliative Care, Amsterdam, the Netherlands

⁵Red Cross Hospital, Department of Anesthesiology, Beverwijk, the Netherlands

⁶Meander Medisch Centrum, Department of Medical Oncology, Amersfoort, the Netherlands

⁷Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands

⁸Antoni van Leeuwenhoek, Netherlands Cancer Institute, Department of Medical Oncology, Amsterdam, the Netherlands

Van N. Trinh, Joseph E. Villaluz

Department of Anesthesiology, Kaweah Health Medical Center, Visalia, California, USA

Filipe Antunes

Physical and Rehabilitation Medicine department & Chronic Pain Unit, Hospital de Braga, Sete fontes-São Victor, Braga, Portugal

Robert S Katz¹*, Frank Leavitt², Ben J Small³

¹Section of Rheumatology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL, USA

²Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA

³Department of Rheumatology, Northwestern Memorial Hospital, Chicago, IL, USA

Jay Suggs*, Garrett G. Perry

Crestwood Medical Center, One Hospital Drive, Huntsville, AL, USA

Anudeep Jafra¹, Jeetinder Kaur Makkar¹*, Nidhi Bhatia¹, Narinder Pal Singh²

¹Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India

²Department of Anaesthesia, MMIMSR, MM (DU), Mullana-Ambala, India

Caesarean delivery is one of the commonest surgical procedures being performed world-wide, and with it comes the burden for management of acute post-operative pain in parturient. A number of modalities including neuraxial opioids, intravenous drugs and truncal nerve blocks are available to control acute postsurgical pain. Quadratus lumborum block has recently been emerged as a modality for pain relief following caesarean delivery. This review highlights the anatomical aspects, mechanism of action of block, relevant literature search and future directions for use of quadratus lumborum block in parturient undergoing caesarean delivery.

Elad Dana^1,2*, James S. Khan³

¹Department of Anesthesia, Intensive Care and Pain Medicine, Meir Medical Center, Kfar Saba, Israel. Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel

²Department of Anesthesia and Pain Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada

³Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada

Jonathan Nieves^*, Tarig S. Elhakim, Valentina Rojas Ortiz, Gabriell Silva, Robert Hernandez, Jose Gascon

Department of Internal Medicine, Kendall Regional Medical Center, Miami, Florida, USA

COVID-19 has been associated with multiple complications including Acute Respiratory Distress Syndrome (ARDS), thrombo-embolism, and septic shock. A rare complication is a Spontaneous pneumomediastinum (SPM), pneumothorax (PNX), and subcutaneous emphysema (SCE) unrelated to positive pressure ventilation. These complications can become life threatening if a large amount of air is present and cannot escape to the neck or retroperitoneum causing obstructive shock or tension pneumothorax. Studies suggest that the cytokine storm in COVID-19 can result in diffuse alveolar injury, which can result in the alveolar wall being vulnerable to rupture. It is also speculated that the cause of the alveolar rupture is due to the diffuse alveolar damage resulting in air leak to the mediastinum. A recent case series of COVID19 autopsies have identified the microthrombi formation and the mononuclear response that leads to diffuse alveolar damage. In addition, recent studies have shown that COVID 19 infected patients are associated with worse clinical outcomes and increase intra and postoperative pulmonary complications and mortality risk. Meaning that patients with SPM had a higher chance of intubation and a higher chance of death. For anesthesiologists, the preoperative evaluation and risk assessment have always been a crucial step in determining whether it is safe to take a patient for surgery. Studies have shown that patients who test positive for COVID 19 are associated with worse clinical outcomes and increase postoperative complications and mortality. Obtaining accurate information, using clinical judgement and having open communication with surgeons may help reduce these risks.

Karishma Kodia^*, Dao M. Nguyen

Section of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida, USA

Enhanced recovery after surgery protocols (ERAS^®) have become increasingly popular in the past few decades. Initially instituted by csolorectal and gynecologic surgery, these optimized "fast track" pathways have expanded across surgical sub-specialties. We discuss critical components of such pathways, the implementation process, and particular facets of perioperative care that apply to various surgical subspecialties including cardiac, colorectal, gynecologic, and thoracic surgery. The spirit of ERAS^® emphasizes a continuous internal auditing process. ERAS^® protocols are known for faster recovery, shorter length of stay, improved pain control, and optimization of a patient’s perioperative course by way of a standardized protocol. The unique aspects of enhanced recovery after thoracic surgery (ERATS) protocols are discussed. We focus on intercostal nerve blocks as an important component of ERATS pathways and optimized postoperative pain control. Intercostal nerve blocks in thoracic surgery allow for excellent postoperative pain control, which is critical for early ambulation, improved chest physiotherapy and easier progression through the post-operative course. This mini-review serves to highlight key features of ERAS^®, salient aspects of niche surgical specialties, and focuses on thoracic surgery enhanced recovery protocols and intercostal nerve blocks in the context of ERATS for optimized postoperative pain control.

Bernice Ofosu¹, Dan Ofori², Michael Ntumy^1,3, Kwaku Asah-Opoku^1,3, Theodore Boafor^1,3*

¹Department of Obstetrics & Gynaecology, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana

²University of Ghana Business School, Legon, Ghana

³University of Ghana Medical School, Korle-Bu, Accra, Ghana

Heather R. Walker^1*, Heather Mueller¹, Tyson Christensen¹, Heidi Cozart¹, Scott R. Junkins²

¹University of Utah Health, Medical Group, Utah, USA

²University of Utah Health, Department of Anesthesiology, Utah, USA

Background: Following the publication of the Center for Diseases Control and Prevention Guidelines for Prescribing Opioids in Primary Care, providers and institutions alike have been modifying practices and policies for prescribing controlled substances (2016).

Study Setting:The University of Utah Health implemented a series of data-driven adaptive and innovative programs and initiatives to improve opioid prescribing across its connected hospital and ambulatory health centers.

Data Collection: Using data mined from the electronic heath record system, researchers have been developing a data-driven approach with a collaborative team spanning clinical and data analytics backgrounds.

Objective: This article discusses those collaborative initiatives and presents a discussion of mindfulness in prescribing practices.

Conclusion: The multi-tiered data-driven approach taken by the University of Utah collaborative team demonstrates a model of change that other health care systems can emulate.

Stacia B. Shipman*, Kelly A. Painter

Department of Emergency Medicine, INTEGRIS Southwest Medical Center, Oklahoma City, OK, USA

Corneal abrasions are known to be extremely painful and are a commonly seen eye condition. Topical anesthetic drops used for diagnosis of corneal abrasions provide immediate pain relief for most patients, but their use for outpatient use has been controversial. There is lack of consensus regarding ideal management of pain associated with corneal abrasions, with some physicians prescribing nonsteroidal anti-inflammatory drugs or opioids which both can have serious side-effects and/or abuse potential. In recent years, several studies have been conducted to assess the efficacy and safety of short term topical anesthetic use for the treatment of acute corneal abrasions. For this review, four published randomized controlled trials were identified that focused on the effectiveness and safety of various topical analgesics used in treating corneal abrasions. These showed varying degrees of efficacy depending on the outcomes measured without any significant difference in complication rates. Additionally, we reviewed an observational study that investigated whether routinely sending corneal abrasion patients home with a 24-hour supply of topical tetracaine is safe. They found no increased risk of ED revisits, fluorescein uptake at follow up, or ophthalmology clinic referrals. Larger prospective studies are still required to establish definitive safety, but the current available evidence suggests use of topical anesthetics for simple corneal abrasions is efficacious and safe.

Joanna R. O'Sullivan^*, Nicola Crowley

Guys and St Thomas's NHS Foundation Trust, UK

The recent publication of a new framework for practice from the British Association of Perinatal Medicine has altered the management of babies born in the UK at the threshold of viability. A risk stratification is used to determine which infants will receive active management, and which receive palliative management. This is achieved through a combination of assessment of risk factors and discussion with parents. The most notable feature of the new framework is the recommendation to consider babies of 22 weeks gestation for active care. This has been the subject of much discussion amongst neonatal and obstetric teams. The framework also emphasises the importance of early transfer to a maternity unit with a co-located neonatal intensive care unit if active management is pursued. This new guidance has led to a change in the way the management of extreme prematurity is approached, and will continue to impact on neonatal, obstetric, and anaesthetic care.

Fariba Farrokhi¹, Sneha Priyadarshini Honnabovi¹, Marisa Pavone¹, Kamal AL-Eryani², Oussama Abousamra³, Reyes Enciso^4*

¹Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

²Assistant Professor of Clinical Dentistry, Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

³Assistant Professor of Clinical Orthopaedic Surgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA

⁴Associate Professor – Instructional, Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

The authors conducted a systematic review and meta-analysis to determine if Core Decompression (CD) with Bone Marrow Stem Cells (BMSC) is more effective in treating Osteonecrosis of the Femoral Head (ONFH) compared to CD. Authors used Cochrane Library, EMBASE, PubMed, Web of Science, and hand-searched references through January 2020, identifying relevant randomized controlled trials (RCTs). Risk of bias was assessed with Cochrane's handbook. Fifty-four abstracts were screened, and eight RCTs (five at high and three at unclear risk of bias) with 432 patients were included. Meta-analyses found statistically significant improvement in Harris Hip Score (HHS) at 12 months (Difference in Means [DM]=10.065;95% Confidence Interval [CI]=4.509 to 15.622; p<0.001) and pain intensity at 24 months (DM=-7.364;95% CI=-12.113 to -2.615;p=0.002) in CD+BMSC group compared to CD alone although these results may not be clinically significant. Risk of Total Hip Replacement (THR) in patients receiving CD+BMSC was 33.4% lower than in CD group though not significant (RR=0.666; 95% CI=0.355 to 1.250;p=0.206). Though meta-analyses found the addition of BMSC to CD significantly improves clinical outcomes (HHS and pain intensity) compared to CD only, evidence was of moderate/low quality due to high risk of bias, imprecision, and small sample sizes. Further research is needed to confirm the results.

Kimberly Ting¹, Albert Huh¹, Carlos J. Roldan^1,2*

¹Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

²McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA

Scope of the investigation: No standard protocol has been established for the treatment of myofascial pain syndrome (MPS). Invasive therapies such as dry needling and trigger point injection (TPI) with active pharmacological agents are commonly used. Growing evidence suggests the efficacy of TPI is independent of the injectate selected. Normal saline (NS) solution has been described as an efficient injectate used in TPI for the treatment of MPS.

Methods: A broad literature search was performed to compare the use of NS and other pharmacological agents as the injectate in TPI for the treatment of MPS.

Results: We identified 13 reports comparing the safety and efficacy of NS with that of botulinum toxin A or local anesthetic with or without steroid in TPI.

Conclusion: Pain of myofascial origin can be adequately treated with TPI independent of the injectate used. The use of NS in TPI offers lower cost, safety, and a more favorable side effect profile than other TPI injectates.

Naveen Manchal

The Prince Charles Hospital, Brisbane, James Cook University, Australia

Erick Gomez-Marroquin¹, Yuka Abe^1,2, Mariela Padilla¹*, Reyes Enciso³, Glenn T. Clark¹

¹Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

²Department of Prosthodontics, Showa University School of Dentistry, Tokyo, Japan. Visitor Scholar Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA

³Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

Aim: To assess treatment efficacy in the management of orofacial myogenous conditions by a retrospective study of patients seen at an orofacial pain clinic.

Methods: A single researcher conducted a retrospective review of charts of patients assigned to the same provider, to identify those with myogenous disorders. The reviewed charts belonged to patients of the Orofacial Pain and Oral Medicine Center of the University of Southern California, seeing from June 2018 to October 2019.

Results: A total of 129 charts included a myogenous disorder; the most common primary myogenous disorder was localized myalgia (58 cases, 45.0%). Arthralgia was the most common TMD concomitant condition (82.9%), followed by internal derangement (41.9%). Forty-six patients were given a home-based conservative physical care protocol; ten additional cases also received trigger point injections (lidocaine or mepivacaine) with pain assessed by verbal numerical rating scale (NRS), pre- and post-treatment follow-up within 24 weeks. There was a significant overall pain improvement in NRS pain from pre- to post-treatment (p<0.001), though no difference was found between conservative treatment and trigger points in NRS pain (p=0.130). However, the rate of NRS unit improvement per week in the conservative treatment group was significantly greater than the trigger point group (p=0.036). These apparently contradictory results might be due to the small sample size of the trigger point injections group (n=10).

Conclusion: In this small sample size study, the addition of trigger point injections to conservative treatment provided inconclusive results, further studies are needed.

Jessi Humphreys*, Laura Schoenherr

Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, USA

As the COVID-19 pandemic proceeds, systems continue to struggle with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high quality patient care. The reduced visitation capacity in hospitals has resulted in high levels of patient and family suffering, and patients both with and without COVID-19 require expert symptom management and goals of care conversations. A manuscript was published describing the rapid implementation of telepalliative medicine consultation by the Inpatient Palliative Care team at UCSF in attempts to meet these critical patient and family needs. This piece details additional lessons learned that were inadequately addressed in the original manuscript and/or that have been revealed in the months since the program’s inception. Key learning points include the need for: committed investment in effective hardware and software; communication skills adapted to effectively utilize technology to benefit patients and families; creative workforce models to render technology effective; interdisciplinary input in care models to reduce provider as well as patient and family suffering; and attention to burdens placed on already overstretched nurses and intensivists during respiratory pandemics.