Search

Objective. With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (e.g., pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain. Setting. Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM). Methods. As a complement to a taxonomy recently developed for chronic pain, the ACTTION public- private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions. Perspective. The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Conclusions. Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions. [ABSTRACT FROM AUTHOR]

Background. Disparity between patient report and physician perception of pain from radiotracer injection for sentinel node biopsy is thought to center on the severity of the intervention, ethnic composition of population queried, and socioeconomic factors. Objective. The objectives of this study were, first, to explore agreement between physicians' and their breast cancer patients' pain assessment during subareolar radionucleotide injection; and second, to evaluate potential ethnic differences in ratings. Methods. A trial was conducted, from January 2006 to April 2009, where 140 breast cancer patients were randomly assigned to standard topical lidocaine-4% cream and 99mTc-sulfur colloid injection, or to one of three other groups: placebo cream and 99mTc-sulfur colloid injection containing NaHCO3, 1% lidocaine, or NaHCO3 + 1% lidocaine. Providers and patients completed numeric pain scales (0-10) immediately after injection. Results. Patients and providers rated pain similarly over the entire cohort (median, 3 vs 2, P = 0.15). Patients rated pain statistically significantly higher than physicians in the standard (6 vs 5, P = 0.045) and placebo + NaHCO3 (5 vs 4, P = 0.032) groups. No significant difference in scores existed between all African Americans and their physicians (3 vs 4, P = 0.27). Conclusion. Patient-physician pain assessment congruence over the less painful injections and their statistically similar scores with the more painful methods suggests the importance of utilizing the least painful method possible. Providers tended to underestimate patients with the highest pain ratings-those in the greatest analgesic need. Lack of statistical difference between African American and physician scores may reflect the equal-access-to-care over the entire patient cohort, supporting the conclusion that socioeconomic factors may lie at the heart of previously reported discrepancies. [ABSTRACT FROM AUTHOR]

Morphine and other opioid drugs have played a major role in austere environment pain management since the Civil War, particularly in the military. While the pre-eminence and success of such medications is without question, their use is accompanied by significant side effects that are undesirable in the most advanced medical settings, and are potentially devastating in the field environment. Recently, there have been significant improvements in pain care for America's wounded service members, along with a shift in how many care providers view pain management. An increasing number of healthcare providers are seeing pain not merely as a symptom, but as a disease process. In addition to dramatically improving care for wounded service members, the evolution in the military's approach to pain is enhancing care for civilians. [ABSTRACT FROM AUTHOR]

Objective. A regional anesthesia complication grading system (regional anesthesia outcomes reporting [ROAR]) was developed and applied to 1,213 consecutive patients over a 14-month period. The goal of the project was the creation of a system to standardize complication reporting in the regional anesthesia literature. Design. Patient demographics, status as a war casualty, regional block procedure-specific details, and complication grade were entered into an Internet-based, encrypted Department of Defense database. Regional anesthesia complications were later graded and subcategorized depending on what phase of the block the procedural adverse event took place. Results. One thousand ninety-eight (90.5%) patients had neither regional anesthesia associated technical difficulties or more severe complications. Of a total of 147 cases with adverse events among 115 patients (1.3 per patient), the majority (63.3%, 93/147) were low-grade complications resulting in no significant morbidity. The most common complications resulting in patient morbidity were failed block requiring catheter removal and/or supplemental block (35.4%, 17/48). High grade complications represented only 4.1% (6/147) of all peri-procedural morbidity. These complications included pneumothorax requiring tube thoracostomy, transient laryngeal nerve dysfunction, and cancellation of planned operation after peripheral nerve block or catheter placement. Conclusions. The value of the ROAR system is that it identifies important issues in risk management in regional anesthesia, thereby providing opportunities for further investigation and clinical practice refinement. Furthermore, it provides for a common language when reporting outcomes in the regional anesthesia literature. Use of the ROAR system will provide consistency in outcomes reporting and facilitate comparisons between methods and procedures. [ABSTRACT FROM AUTHOR]

Objective. Consistent and reliable standards for reporting of regional anesthetic adverse events are lacking. The quality of reporting of regional anesthetic morbidity has not been assessed critically. Aim. To evaluate quality of regional anesthesia outcomes reporting. Methods. Published retrospective or prospective observational cohort or randomized controlled trials in peer-reviewed journals were reviewed, and judged according to seven criteria related to quality of reporting of regional anesthesia complications: method of accrual, duration of data collection, definition of complication, morbidity and mortality rates, grade of complication severity, exclusion criteria, and study follow up. Differences in reporting outcomes according to study design, sample size and time period were compared. Results. Ninety-one articles published from 1996–2006 involving 8,833 patients were analyzed. The majority of studies (75%) met ≤4 reporting criteria. Recently published, prospective studies with >200 patients were associated with significantly higher-quality reporting ( P < 0.05). Fewer than 50% of studies reported at least one recognized, accepted complication with defined criteria or indicated duration of follow up. Reporting compliance was worse (29%) for reporting of actual morbidity rates, and complications leading to death. Complication severity grading related to regional anesthesia was reported in 2% of studies. Conclusion. Consistent and comparative regional anesthesia outcome data are lacking in peer-reviewed journals. A graded regional anesthetic morbidity and mortality system according to the intensity of therapy required for the treatment of the defined complication is proposed, along with a structured format for the reporting of regional anesthesia complications according to defined reporting standards. [ABSTRACT FROM AUTHOR]

Introduction. Postoperative pain is a frequent occurrence following breast surgery. Some authors have reported the incidence of postoperative pain following mastectomy and breast reconstruction to be as high as 50% when general anesthesia and intravenous narcotics are the primary anesthetic. An alternative anesthetic technique for breast surgery and postoperative analgesia is paravertebral nerve blockade (PVB). Greengrass and Weltz have described improved patient satisfaction, less analgesic requirement, and less total anesthetic use in those patients with preoperative PVBs. One of the challenges in providing successful analgesia from PVBs is the ability to correctly identify the paravertebral space. Landmark-based anatomy with penetration of the superior costotransverse ligament 1 cm past the transverse process has been previously described. Boezaart has described the use of loss of resistance (LOR) when performing PVBs. One potential difficulty with this technique is the reliance on the subjective feel of resistance loss as the needle passes into the paravertebral space. Case Report. The EpisureTM AutodetectTM Syringe is currently indicated by the US Food and Drug Administration for use with an epidural needle for the verification for needle tip placement in the epidural space. The principle, however, of LOR is similar when performing PVBs. We report a case of the successful use of the EpisureTM AutodetectTM Syringe (ADS) for confirming entry into the paravertebral space. Conclusion. To our knowledge, this is the first described use of the ADS for performing PVB. [ABSTRACT FROM AUTHOR]

Background. The war in Iraq has resulted in a high incidence of severe extremity injury requiring multiple surgical procedures and extensive rehabilitation. We describe the use of advanced regional anesthesia to meet this significant medical challenge. Methods. From March 2003 to December 2004, 4,100 casualties have been evacuated to Walter Reed Army Medical Center (WRAMC). Of 1,400 inpatients, 750 have been battle-injured with 500 having extremity injuries. Of these, 287 (57%) received surgical care incorporating regional anesthesia including single-injection peripheral nerve blocks and continuous peripheral and epidural infusion catheters. Wounding, surgical, anesthetic, and outcomes data have been prospectively collected. Results. Over 900 operations (mean 4 ± 2/patient) were performed on 287 casualties prior to arrival at WRAMC, and 634 operations (mean 2 ± 1/patient) were performed at WRAMC. Thirty-five percent of this cohort was amputees. In the study group, 646 advanced regional anesthesia procedures, including 361 continuous peripheral nerve blocks (CPNBs), were performed with a mean catheter infusion time of 9 days (1–34). Catheter-related complications occurred in 11.9% of casualties and were technical or minor in nature. Catheter-related infection rate was 1.9%. In 126 casualties with indwelling CPNB catheters, a significant decrease in pain score over 7 days was apparent (mean 3.7 ± 0.2 to 2.2 ± 0.2, P < 0.001). Conclusion. Advanced regional anesthetic techniques allowed for safe perioperative surgical anesthesia and analgesia in the management of the modern combat casualty. [ABSTRACT FROM AUTHOR]

Abdominal adhesions are a significant cause of increased morbidity, mortality, and cost in patients undergoing abdominal surgery. Carboxymethylcellulose combined with recombinant tissue plasminogen activator (CMC + rtPA) and Seprafilm (sodium hyaluronate/carboxymethylcellulose bioresorbable membrane) have been shown to reduce adhesion formation in animal models. The effect these treatments may have on a healing bowel anastomosis is unknown. Forty-eight rats underwent a laparotomy and the distal colonic segment was transected and an anastomosis of the transected ends performed. Before abdominal closure one of three treatments - CMC + rtPA, Seprafilm, and saline (control) - was placed in the rat abdomen around the anastomosis. A necropsy was performed 75 to 96 hours later and bowel anastomosis adhesions were scored using an adhesion scale. The anastomosis strength was then evaluated using a saline infusion bursting pressure model. No difference was observed in the extent of adhesion formation involving the bowel anastomosis among all groups. No statistically significant difference was found among the groups in the bursting strength of the colonic anastomosis. We conclude that CMC + rtPA and Seprafilm do not significantly reduce colonic bowel anastomosis bursting strength in the rat model. [ABSTRACT FROM AUTHOR]

Intraperitoneal adhesions are a significant problem (increased morbidity, mortality, and cost) for patients undergoing abdominal procedures. Although a variety of approaches (e.g., fibrinolytic agents, anti-inflammatory drugs, or barrier/separation methods) have been used with some success in preventing adhesions, a comparison of these different modalities has yet to be performed in a model that objectively measures intraperitoneal adhesion formation. Our objectives were to establish an objective, reproducible model of intraperitoneal adhesion formation and to establish efficacy of different treatment modalities in decreasing the strength and extent of intraperitoneal adhesions. In this two-part study, a rat model establishing an objective measure of both the strength and extent of intraperitoneal adhesions was used to compare different treatment modalities. Fibrinolytic agents [recombinant tissue plasminogen activator (rtPA), streptokinase, and urokinase], anti-inflammatory drugs (dexamethasone and tolmetin sodium), and barrier methods [sodium carboxymethylcellulose (CMC), and sodium hyaluronate] and a control group were compared in the first phase. In the second phase, the two most successful agents (rtPA, CMC) were compared both alone and in combination against a commercially available barrier agent (Seprafilm) and a control group. In the first phase of the study, rtPA was the only agent that had a statistically significant effect in decreasing the strength of adhesions. CMC was the only agent that demonstrated a decrease in the extent of adhesions, and the difference tended toward significance. In the second phase, the combination of rtPA and CMC showed a significant decrease in both the strength and extent of adhesions when compared with those of the control group. This decrease was also observed in the group treated with Seprafilm, which showed no difference from the rtPA + CMC group. We conclude that, in this reproducible adhesion model, only the combination of rtPA + CMC and Seprafilm significantly reduced both the strength and the extent of intraperitoneal adhesions. [ABSTRACT FROM AUTHOR]

In this article, the author discusses the science of traditional medicine such as acupuncture and medical massage, and how it can complement modern medicine. The author cites the things that he learned regarding the history of traditional medicine during his medical mission in Vietnam in August 2009. Furthermore, he says that he was fascinated at how the Vietnamese are able to integrate traditional medicine with the practice of modern medicine after reading the book of doctor Patricia Tsang.

Purpose: The purpose of this prospective correlational study was to compare the psychometric properties of the Defense and Veterans Pain Rating Scale (DVPRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scales with those of traditional legacy scales over a longitudinal postoperative period in patients undergoing arthroscopic procedures.Methods: Active-duty military personnel undergoing shoulder and knee arthroscopic procedures completed the DVPRS, PROMIS, and legacy scales preoperatively and again at 3 months postoperatively. Rolling correlation coefficients (rrm) were used to assess the concurrent validity between the DVPRS average pain scores and computer adaptive testing PROMIS scales (Anxiety, Depression, Pain Behavior, Pain Interference, Mobility, Sleep Disturbance, Satisfaction With Social Roles, and Upper Extremity Physical Function) and the legacy scales (American Shoulder and Elbow Surgeons [ASES] scale, Shoulder Activity Scale, International Knee Documentation Committee [IKDC] questionnaire, Single Assessment Numeric Evaluation [SANE], Marx Activity Rating Scale, and Veterans RAND 12-Item Health Survey).Results: A total of 121 participants completed the scales preoperatively, 80 completed them at 3 months postoperatively, and 59 (49% of participants) completed them at both times. Rolling correlation coefficients between PROMIS Pain Interference (rrm = -0.41, P = .006), Satisfaction With Social Roles (rrm = 0.56, P < .001), and Upper Extremity (rrm = 0.71, P < .001) scores showed acceptable concurrent validity with ASES scores over a longitudinal postoperative period. DVPRS scores (rrm = -0.69, P = .002) and PROMIS Pain Behavior (rrm = -0.57, P = .018), Pain Interference (rrm = -0.71, P = .001), Sleep Disturbance (rrm = -0.64, P = .005), and Mobility (rrm = 0.65, P = .005) scores showed acceptable concurrent validity with IKDC scores. There was poor correlation between the PROMIS and DVPRS scores and the Single Assessment Numeric Evaluation, Marx Activity Rating Scale, Shoulder Activity Scale, and Veterans RAND 12-Item Health Survey scores.Conclusions: PROMIS scales measuring physical function, pain presentation, and other health domains showed acceptable concurrent validity with ASES and IKDC scores. By integrating the prospective collection of biopsychosocial PROMIS scales into practice, it is possible for clinicians in orthopaedic settings to assess changes in validated patient-reported outcomes to inform patient-centered care planning throughout the postoperative recovery period.Level Of Evidence: Level II, prospective comparative study (with not all participants completing follow-up). [ABSTRACT FROM AUTHOR]

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based model that provides high-quality medical education for common and complex diseases through telementoring and comanagement of patients with primary care clinicians. In a one to many knowledge network, the ECHO model helps to bridge the gap between primary care clinicians and specialists by enhancing the knowledge, skills, confidence, and practice of primary care clinicians in their local communities. As a result, patients in rural and urban underserved areas are able to receive best practice care without long waits or having to travel long distances. The ECHO model has been replicated in 43 university hubs in the United States and five other countries. A new replication tool was developed by the Project ECHO Pain team and U.S. Army Medical Command to ensure a high-fidelity replication of the model. The adoption of the tool led to successful replication of ECHO in the Army Pain initiative. This replication tool has the potential to improve the fidelity of ECHO replication efforts around the world. [ABSTRACT FROM AUTHOR]

Dexmedetomidine (DEX) is an α-2 receptor agonist with sedative and analgesic properties. It has been reported to preserve the patient's ability to cooperate and provide opioid sparing properties. Patients with obstructive sleep apnea (OSA) have demonstrated an increased risk for oxygen desaturation following general anesthesia. We report a case of a 64-year-old male. ASA IV with severe chronic obstructive pulmonary disease, OSA, unilateral vocal cord dysfunction, gastro-esophageal reflux disease, and congestive heart failure undergoing an awake thyroidectomy under local anesthesia and a DEX infusion. The patient was given a loading dose of DEX of 1 mcg/kg and an infusion ranging from 0.2 to 1.0 g/kg/hr. He received a total of 250 meg of fentanyl and 7.5 mg of ketorolac throughout the case. Results: The patient tolerated the procedure well. He was able to cooperate with simple commands. His vital signs remained stable. He reported a pain score of 2 out of 10 in the recovery unit. Conclusions: This case demonstrates the successful use of a DEX infusion along with local anesthesia administered by the surgeon for an awake thyroidectomy. [ABSTRACT FROM AUTHOR]