Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Nov 2018
ReviewEsmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care.
β-Adrenergic blockade is an important mechanism for reducing morbidity and mortality in patients with hypertension and heart failure. Esmolol has been used widely for its chronotropic and antihypertensive effects. However, there has been recent inquiry regarding perioperative esmolol use and nociceptive modulation. ⋯ Esmolol, to date, has not shown any direct analgesic or anesthetic properties; however, recent studies suggest that esmolol may have antinociceptive and postoperative opioid-sparing effects. In this Daring Discourse narrative, we describe the role of esmolol in current perioperative β-blockade guidelines (related to noncardiac surgery), briefly describe studies supporting the antinociceptive effects of esmolol, propose mechanisms for esmolol antinociception, and forecast potential routine esmolol use intraoperatively (as part of a multimodal total intravenous anesthetic) and its effects on opioid sparing. The reading audience of regional anesthesiologists and acute pain medicine physicians is uniquely positioned to take a lead role in promulgating this care advance amid (i) the unwanted effects of the opioid epidemic and (ii) the uncertain notion of whether routine general anesthesia care (with fentanyl) may indirectly be contributing to the epidemic.
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Reg Anesth Pain Med · Oct 2018
ReviewGastric Ultrasound for the Regional Anesthesiologist and Pain Specialist.
This article in our series on point-of-care ultrasound (US) for the regional anesthesiologist and pain management specialist describes the emerging role of gastric ultrasonography. Although gastric US is a relatively new point-of-care US application in the perioperative setting, its relevance for the regional anesthesiologist and pain specialist is significant as our clinical practice often involves providing deep sedation without a secured airway. Given that pulmonary aspiration is a well-known cause of perioperative morbidity and mortality, the ability to evaluate for NPO (nil per os) status and risk stratify patients scheduled for anesthesia is a powerful skill set. ⋯ In this review, we will cover the relevant scanning technique and the desired views for gastric US. We provide a methodology for interpretation of findings and for guiding medical management for adult patients. We also summarize the current literature on specific patient populations including obstetrics, pediatrics, and severely obese subjects.
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Reg Anesth Pain Med · Jul 2018
ReviewConsensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.
Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. ⋯ Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.
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Despite a growing awareness about the importance of gender equity and the rising number of women in medicine, women remain persistently underrepresented in pain medicine and anesthesiology. Pain medicine ranks among the bottom quartile of medical specialties in terms of female applicants, female trainees, and proportion of female practitioners. ⋯ Increased gender diversity among pain medicine physicians is vital to fostering excellence in pain research, education, and clinical care, as well as creating a high-quality work environment. Pain medicine stands at a crossroads as a specialty, and must examine reasons for its current gender gap and consider a call to action to address this important issue.
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Reg Anesth Pain Med · May 2018
Meta AnalysisLiterature Review and Meta-Analysis of Transcutaneous Electrical Nerve Stimulation in Treating Chronic Back Pain.
This study is a meta-analysis of randomized controlled trials comparing the efficacy of transcutaneous electrical nerve stimulation (TENS) to a control and to other nerve stimulation therapies (NSTs) for the treatment of chronic back pain. ⋯ These results suggest that TENS does not improve symptoms of lower back pain, but may offer short-term improvement of functional disability.