Background: Enhanced Recovery After Surgery (ERAS) is multidisciplinary, evidence-based approach in the perioperative care of surgical patients that aims to reduce postoperative complications, length of hospital stay, readmissions and healthcare costs by implementing protocols throughout patient’s perioperative journey. (1) The purpose of this review is to highlight the pharmacologic perspective of the most common drugs utilised in ERAS protocols, present current evidence regarding optimal and individualised use of them, discuss ways how clinicians can maximise the benefits of their patients and outline future advancements in the field. Methods: A wide literature search was performed to identify high quality evidence on the pharmacology of common analgesics and local anaesthetics used in ERAS protocols. PubMed, Embase and Scopus databases were searched using various combinations of terms related to perioperative analgesia, personalised/precision/individualised medicine, local anaesthetics and Enhanced Recovery after Surgery protocols, up to January 2021. Results: Literature search revealed known and less known pharmacological properties of common analgesics and local anaesthetics, unveiled pharmacodynamic, pharmacokinetic and pharmacogenomic properties of drugs that can improve efficiency and reduce adverse-effects with a more individualised patient approach and suggested evidence-based ways of serving the purposes of ERAS protocols. Conclusions: Clinical Pharmacology plays an essential role in improving patient care within ERAS pathways by implementing basic and advanced pharmacologic properties and pharmacogenomic data towards a more patient-centered approach.
{"title":"The individualised Pharmacologic approach of Enhanced Recovery After Surgery (ERAS) pathways: Analgesics and local anaesthetics","authors":"Georgios S. Papageorgiou, V. Manolopoulos","doi":"10.22514/sv.2021.181","DOIUrl":"https://doi.org/10.22514/sv.2021.181","url":null,"abstract":"Background: Enhanced Recovery After Surgery (ERAS) is multidisciplinary, evidence-based approach in the perioperative care of surgical patients that aims to reduce postoperative complications, length of hospital stay, readmissions and healthcare costs by implementing protocols throughout patient’s perioperative journey. (1) The purpose of this review is to highlight the pharmacologic perspective of the most common drugs utilised in ERAS protocols, present current evidence regarding optimal and individualised use of them, discuss ways how clinicians can maximise the benefits of their patients and outline future advancements in the field. Methods: A wide literature search was performed to identify high quality evidence on the pharmacology of common analgesics and local anaesthetics used in ERAS protocols. PubMed, Embase and Scopus databases were searched using various combinations of terms related to perioperative analgesia, personalised/precision/individualised medicine, local anaesthetics and Enhanced Recovery after Surgery protocols, up to January 2021. Results: Literature search revealed known and less known pharmacological properties of common analgesics and local anaesthetics, unveiled pharmacodynamic, pharmacokinetic and pharmacogenomic properties of drugs that can improve efficiency and reduce adverse-effects with a more individualised patient approach and suggested evidence-based ways of serving the purposes of ERAS protocols. Conclusions: Clinical Pharmacology plays an essential role in improving patient care within ERAS pathways by implementing basic and advanced pharmacologic properties and pharmacogenomic data towards a more patient-centered approach.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45711608","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
K. Theodoraki, Sofia Hadzilia, D. Valsamidis, K. Kalopita, E. Stamatakis
Background and goal of study: Spinal anesthesia for cesarean section can be frequently complicated by hypotension, with untoward effects for both the mother and fetus. Recently, norepinephrine has been shown to be effective in maintaining blood pressure in obstetric patients. Another technique widely used to prevent hypotension is fluid administration. Current evidence suggests that the combination of fluid administration and vasoconstrictive medications should be the main strategy for prevention and management of hypotension. The aim of this randomized study was to investigate the combination of a norepinephrine infusion and colloid preloading versus the combination of a norepinephrine infusion and crystalloid co-loading for the prevention of maternal hypotension during elective cesarean section under combined spinal-epidural anaesthesia Materials and methods: One hundred parturients were randomized to receive either 6% hydroxyethyl starch 130/0.4 5 mL/kg before spinal anesthesia (colloid preload) or Ringer’s Lactate solution 10 mL/kg starting with intrathecal injection (crystalloid co-load). Both groups were also administered norepinephrine 4 μg/min, starting simultaneously with the administration of the subarachnoid solution. The primary outcome was the incidence of maternal hypotension (SBP <80% of baseline). The incidence of severe hypotension (SAP <80 mmHg), total dose of ephedrine administered as well as maternal side-effects and the acid-base status and Apgar score of the neonate were also recorded Results: There were no significant differences in the incidence of hypotension (13.7% vs. 16.3%, P = 0.933 or severe hypotension (0% vs. 4%, P = 0.238) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 0 [0–15] mg in the colloid preload group and 0 [0–10] mg in the crystalloid co-load group (P = 0.807). There were no significant differences in maternal side-effects or neonatal outcomes between groups Conclusion: The incidence of hypotension during elective cesarean section is low and comparable when a norepinephrine infusion is used in combination with either colloid preload or crystalloid co-load, with perhaps a marginal superiority of colloid preload in the prevention of severe hypotension. It appears that the optimal regimen for prevention of maternal hypotension is a combination of fluids and a prophylactic vasopressor like norepinephrine.
{"title":"Comparison of colloid preloading and continuous infusion of norepinephrine versus crystalloid co-loading and continuous infusion of norepinephrine in the prevention of maternal hypotension","authors":"K. Theodoraki, Sofia Hadzilia, D. Valsamidis, K. Kalopita, E. Stamatakis","doi":"10.22514/sv.2021.168","DOIUrl":"https://doi.org/10.22514/sv.2021.168","url":null,"abstract":"Background and goal of study: Spinal anesthesia for cesarean section can be frequently complicated by hypotension, with untoward effects for both the mother and fetus. Recently, norepinephrine has been shown to be effective in maintaining blood pressure in obstetric patients. Another technique widely used to prevent hypotension is fluid administration. Current evidence suggests that the combination of fluid administration and vasoconstrictive medications should be the main strategy for prevention and management of hypotension. The aim of this randomized study was to investigate the combination of a norepinephrine infusion and colloid preloading versus the combination of a norepinephrine infusion and crystalloid co-loading for the prevention of maternal hypotension during elective cesarean section under combined spinal-epidural anaesthesia Materials and methods: One hundred parturients were randomized to receive either 6% hydroxyethyl starch 130/0.4 5 mL/kg before spinal anesthesia (colloid preload) or Ringer’s Lactate solution 10 mL/kg starting with intrathecal injection (crystalloid co-load). Both groups were also administered norepinephrine 4 μg/min, starting simultaneously with the administration of the subarachnoid solution. The primary outcome was the incidence of maternal hypotension (SBP <80% of baseline). The incidence of severe hypotension (SAP <80 mmHg), total dose of ephedrine administered as well as maternal side-effects and the acid-base status and Apgar score of the neonate were also recorded Results: There were no significant differences in the incidence of hypotension (13.7% vs. 16.3%, P = 0.933 or severe hypotension (0% vs. 4%, P = 0.238) between colloid preload and crystalloid co-load groups, respectively. The median [range] ephedrine dose was 0 [0–15] mg in the colloid preload group and 0 [0–10] mg in the crystalloid co-load group (P = 0.807). There were no significant differences in maternal side-effects or neonatal outcomes between groups Conclusion: The incidence of hypotension during elective cesarean section is low and comparable when a norepinephrine infusion is used in combination with either colloid preload or crystalloid co-load, with perhaps a marginal superiority of colloid preload in the prevention of severe hypotension. It appears that the optimal regimen for prevention of maternal hypotension is a combination of fluids and a prophylactic vasopressor like norepinephrine.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46635018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: The use of a local anesthetic solution with opioids as a continuous epidural infusion administration during labor is controversial. It is considered to prolong the second stage of labor and to increase the total delivered dose of anesthetic, without improving the analgesia in comparison with the usage of the same solution in intermittent bolus doses, periodically. This study is designed to compare these two techniques. Materials and methods: In this study, 60 parturient women were included. Labor analgesia started with a single bolus dose of 10 mL ropivacaine 0.1% administered epidurally in both groups. Group A was, subsequently, given epidurally Ropivacaine 0.15% with Fentanyl 2 μgr/mL in continuous infusion with a rate of 10 mL/h throughout labor, while Group B was given the same dose per hour but in two bolus doses of 5 mL administered every 30 min. In both groups, we had the possibility of additional bolus doses of 5 mL of the same solution with a lock out interval of 20 min. The total dosage received, the duration of the 2nd stage of labor, the method of delivery (assisted or not, Cesarean section), the motor activity (using the Bromage scale) and the pain intensity (using the VAS 1–10, every 20 min) were evaluated. Results: No statistically significant differences were observed in the duration of labor (one way ANOVA), in the Bromage score and in the method of delivery between the two groups (x2 test). No differences were also observed in the recordings of pain intensity between the two groups (two-way ANOVA for repeated measurements), but in some specific instances Group A presented higher VAS score, although the total dosage of local anesthetic received was greater in this group compared to group B (180 mL vs. 162 mL, p = 0.04). Conclusions: The use of intermittent epidural bolus doses compared to a continuous infusion technique is associated with lower total consumption and periodically better pain management.
导读:在分娩过程中使用含阿片类药物的局部麻醉溶液作为硬膜外持续输注是有争议的。它被认为延长第二产程，增加麻醉剂的总剂量，而不改善镇痛与使用相同的溶液间歇大剂量，定期。本研究旨在比较这两种技术。材料与方法:本研究纳入产妇60例。分娩镇痛开始时，两组均在硬膜外给药10ml 0.1%罗哌卡因。A组,随后,由于硬膜外Ropivacaine 0.15%与芬太尼在连续输注2μgr /毫升10毫升/小时的速度在劳动力,而B组被赋予相同的剂量每小时但两丸剂量的5毫升每30分钟。管理两组,我们有额外的5毫升剂量的可能性相同的解决方案与一个锁间隔20分钟。总剂量收到,第二阶段的持续时间的劳动,交付的方法(协助,剖宫产)、运动活动(使用Bromage评分)和疼痛强度(使用VAS 1-10评分，每20分钟一次)进行评估。结果:两组分娩时间(单因素方差分析)、Bromage评分、分娩方式差异均无统计学意义(x2检验)。两组之间的疼痛强度记录也没有差异(重复测量的双向方差分析)，但在某些特定情况下，A组的VAS评分更高，尽管该组接受的局麻总剂量大于B组(180 mL对162 mL, p = 0.04)。结论:与连续输注技术相比，间歇硬膜外注射剂量的使用与更低的总消耗和周期性更好的疼痛管理有关。
{"title":"Comparison of two different methods for labor analgesia depending on the mode of epidural infusion administration (continuous or intermittent)","authors":"Spanopoulos Konstantinos, Anagnostou Georgios, P. K. Ioiannis, Papagiannopoulou Ofilia, Zografidou Polixeni, Tsiotsiou Maria, Gogali Despoina, Pinas Dimitrios, Grenda Georgia, Grigoriou Ioulia, Goutziomitrou Evangelia","doi":"10.22514/sv.2021.167","DOIUrl":"https://doi.org/10.22514/sv.2021.167","url":null,"abstract":"Introduction: The use of a local anesthetic solution with opioids as a continuous epidural infusion administration during labor is controversial. It is considered to prolong the second stage of labor and to increase the total delivered dose of anesthetic, without improving the analgesia in comparison with the usage of the same solution in intermittent bolus doses, periodically. This study is designed to compare these two techniques. Materials and methods: In this study, 60 parturient women were included. Labor analgesia started with a single bolus dose of 10 mL ropivacaine 0.1% administered epidurally in both groups. Group A was, subsequently, given epidurally Ropivacaine 0.15% with Fentanyl 2 μgr/mL in continuous infusion with a rate of 10 mL/h throughout labor, while Group B was given the same dose per hour but in two bolus doses of 5 mL administered every 30 min. In both groups, we had the possibility of additional bolus doses of 5 mL of the same solution with a lock out interval of 20 min. The total dosage received, the duration of the 2nd stage of labor, the method of delivery (assisted or not, Cesarean section), the motor activity (using the Bromage scale) and the pain intensity (using the VAS 1–10, every 20 min) were evaluated. Results: No statistically significant differences were observed in the duration of labor (one way ANOVA), in the Bromage score and in the method of delivery between the two groups (x2 test). No differences were also observed in the recordings of pain intensity between the two groups (two-way ANOVA for repeated measurements), but in some specific instances Group A presented higher VAS score, although the total dosage of local anesthetic received was greater in this group compared to group B (180 mL vs. 162 mL, p = 0.04). Conclusions: The use of intermittent epidural bolus doses compared to a continuous infusion technique is associated with lower total consumption and periodically better pain management.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43170109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
“I can’t cope with this”, “Why me?”, “What if it worsens?”. These thoughts swirl in our mind when we are in pain. Soon we feel anxiety, stress, depression, irritability and exhaustion, which amplify the pain. Suffering occurs on two levels. Firstly, there are the actual unpleasant sensations felt in the body (Primary Suffering) as a result of an injury, and ongoing illness or changes to the nervous system. On top of this is the Secondary Suffering, which is made up of all the thoughts, feelings, and emotions associated with the pain. When we are in pain, we actually feel is a fusion of both. UK is moving towards a more holistic approach to pain management, referring many patients to alternative programs including Mindfulness. With Mindfulness, people are in a better position to distinguish what causes their pain, dissolve the Secondary Suffering and, many times, see Primary Suffering to dimmish. Mindfulness meditation was initially brought into clinical healthcare in 1979 by Prof. Jon Kabat-Zinn. He developed the MBSR program at the University of Massachusetts and since then numerous scientific studies measure its efficacy: when it comes to pain, mindfulness can be as effective as the main prescription painkillers. Many hospital clinics abroad prescribe mindfulness meditation to help patients cope effectively with a range of diseases such as cancer, heart disease, diabetes, arthritis, back problems, fibromyalgia a.o. A taste of this program is included in our Workshop. We will cultivate a closer relationship with out body and breath, we will accept pain whilst taking care of ourselves, we will appreciate the pleasant experiences and also acknowledge the difficulties in life, we will be reminded that we are interconnected with other people and, finally, we will acknowledge that although we can’t control what life throws on us, we can choose how to respond.
“我应付不了”，“为什么是我?”、“如果情况恶化怎么办?”当我们痛苦时，这些想法就会在我们的脑海中盘旋。很快我们就会感到焦虑、压力、抑郁、易怒和疲惫，这些都放大了痛苦。痛苦有两个层次。首先，由于受伤、持续的疾病或神经系统的变化，身体实际感受到的不愉快的感觉(主要痛苦)。在此之上是次级痛苦，它由所有与痛苦相关的思想、感觉和情绪组成。当我们在痛苦的时候，我们所感受到的其实是两者的融合。英国正朝着更全面的疼痛管理方法迈进，将许多患者推荐到包括正念在内的替代方案。有了正念，人们就能更好地分辨出是什么导致了他们的痛苦，化解了次级痛苦，很多时候，看到主要的痛苦消失了。正念冥想最初是由Jon Kabat-Zinn教授于1979年引入临床医疗保健的。他在马萨诸塞大学(University of Massachusetts)开发了正念减压疗法(MBSR)，从那以后，无数科学研究衡量了它的功效:当涉及到疼痛时，正念可以和主要的处方止痛药一样有效。许多国外的医院诊所开正念冥想来帮助病人有效地应对一系列疾病，如癌症、心脏病、糖尿病、关节炎、背部问题、纤维肌痛等。我们将培养与我们的身体和呼吸更密切的关系，我们将接受痛苦，同时照顾好自己，我们将欣赏快乐的经历，也承认生活中的困难，我们将被提醒，我们与其他人是相互联系的，最后，我们将承认，虽然我们不能控制生活抛给我们的东西，我们可以选择如何回应。
{"title":"Mindfulness: Its application in pain management and the improvement of the quality of life","authors":"Despina Yannouli","doi":"10.22514/sv.2021.207","DOIUrl":"https://doi.org/10.22514/sv.2021.207","url":null,"abstract":"“I can’t cope with this”, “Why me?”, “What if it worsens?”. These thoughts swirl in our mind when we are in pain. Soon we feel anxiety, stress, depression, irritability and exhaustion, which amplify the pain. Suffering occurs on two levels. Firstly, there are the actual unpleasant sensations felt in the body (Primary Suffering) as a result of an injury, and ongoing illness or changes to the nervous system. On top of this is the Secondary Suffering, which is made up of all the thoughts, feelings, and emotions associated with the pain. When we are in pain, we actually feel is a fusion of both. UK is moving towards a more holistic approach to pain management, referring many patients to alternative programs including Mindfulness. With Mindfulness, people are in a better position to distinguish what causes their pain, dissolve the Secondary Suffering and, many times, see Primary Suffering to dimmish. Mindfulness meditation was initially brought into clinical healthcare in 1979 by Prof. Jon Kabat-Zinn. He developed the MBSR program at the University of Massachusetts and since then numerous scientific studies measure its efficacy: when it comes to pain, mindfulness can be as effective as the main prescription painkillers. Many hospital clinics abroad prescribe mindfulness meditation to help patients cope effectively with a range of diseases such as cancer, heart disease, diabetes, arthritis, back problems, fibromyalgia a.o. A taste of this program is included in our Workshop. We will cultivate a closer relationship with out body and breath, we will accept pain whilst taking care of ourselves, we will appreciate the pleasant experiences and also acknowledge the difficulties in life, we will be reminded that we are interconnected with other people and, finally, we will acknowledge that although we can’t control what life throws on us, we can choose how to respond.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41447156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: Local anesthesia for dental procedures is considered relatively safe since, apart of anaphylactic reactions, only rare complications are reported. Visual disturbances such as diplopia that is presented below account for 0.1% of all complications. Method: A 57 year old woman was administered a posterior superior alveolar nerve block for the dental filling of the first right molar tooth with the use of Articaine Hydrochloride 4% with Adrenaline 1:100,000 in a 30 gauze syringe. Soon after she complained of diplopia and dizziness and was referred for evaluation by a specialist. Psychiatric evaluation did not reveal any psychopathology other than the presence of great distress. Neurological examination revealed horizontal diplopia and limitation of the lateral rectus muscle to abduct the right eye. Pupil reaction was normal and no ptosis was present. It was diagnosed right abducent nerve palsy. The patient was reassured of the transient nature of symptoms and the eye was covered to minimize nausea. Symptoms resolved gradually after 90 min. Results: Literature suggests that diplopia occurs most frequently after maxillary injections (77.8% vs 57.1% for mandibular injections) and after posterior superior alveolar nerve block. Various mechanisms, other than improperly placed nerve block are proposed. The most possible hypothesis of retrograde flow of anesthetic solution into the venous system explains that the anesthetic solution, after an accidental entry into the venous system, will drain into the pterygoid venous plexus, and at last into the cavernous sinus, where the abducent nerve is sited. These complications may be related to anatomic variations Conclusion: Diplopia during local anesthesia is very rare and usually transient, however is very alarming and might lead to medicolegal issues. Generally is proposed to always aspirate before injection, stop any procedure and refer the patient if symptoms persist.
简介:局部麻醉用于牙科手术被认为是相对安全的，因为除了过敏反应外，只有罕见的并发症被报道。视力障碍，如复视，如下所示，占所有并发症的0.1%。方法:采用盐酸阿替卡因4%加肾上腺素1:10万，30纱布注射器对57岁女性右第一磨牙进行后上牙槽神经阻滞充填。不久之后，她抱怨复视和头晕，并被介绍给专家评估。精神病学评估没有发现任何精神病理，除了存在巨大的痛苦。神经学检查显示水平复视和限制外直肌外展右眼。瞳孔反应正常，无上睑下垂。诊断为右外展神经麻痹。使患者确信症状是短暂性的，并遮盖眼睛以减少恶心。结果:文献显示上颌注射(77.8% vs .下颌骨注射57.1%)和后上牙槽神经阻滞后复视发生率最高。除了神经阻滞放置不当外，还提出了多种机制。麻醉溶液逆行进入静脉系统的最可能的假说解释说，麻醉溶液在意外进入静脉系统后，会流入翼状静脉丛，最后流入外展神经所在的海绵窦。结论:局麻复视是一种非常罕见且通常是短暂性的复视，但却非常令人担忧并可能导致医学法律问题。通常建议在注射前总是抽吸，停止任何程序，如果症状持续，请转诊。
{"title":"Diplopia due to local anesthesia. A very rare complication","authors":"Emmanuel Kapiris, K. Kosma, Fani Kremastinou","doi":"10.22514/sv.2021.185","DOIUrl":"https://doi.org/10.22514/sv.2021.185","url":null,"abstract":"Introduction: Local anesthesia for dental procedures is considered relatively safe since, apart of anaphylactic reactions, only rare complications are reported. Visual disturbances such as diplopia that is presented below account for 0.1% of all complications. Method: A 57 year old woman was administered a posterior superior alveolar nerve block for the dental filling of the first right molar tooth with the use of Articaine Hydrochloride 4% with Adrenaline 1:100,000 in a 30 gauze syringe. Soon after she complained of diplopia and dizziness and was referred for evaluation by a specialist. Psychiatric evaluation did not reveal any psychopathology other than the presence of great distress. Neurological examination revealed horizontal diplopia and limitation of the lateral rectus muscle to abduct the right eye. Pupil reaction was normal and no ptosis was present. It was diagnosed right abducent nerve palsy. The patient was reassured of the transient nature of symptoms and the eye was covered to minimize nausea. Symptoms resolved gradually after 90 min. Results: Literature suggests that diplopia occurs most frequently after maxillary injections (77.8% vs 57.1% for mandibular injections) and after posterior superior alveolar nerve block. Various mechanisms, other than improperly placed nerve block are proposed. The most possible hypothesis of retrograde flow of anesthetic solution into the venous system explains that the anesthetic solution, after an accidental entry into the venous system, will drain into the pterygoid venous plexus, and at last into the cavernous sinus, where the abducent nerve is sited. These complications may be related to anatomic variations Conclusion: Diplopia during local anesthesia is very rare and usually transient, however is very alarming and might lead to medicolegal issues. Generally is proposed to always aspirate before injection, stop any procedure and refer the patient if symptoms persist.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43954667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The still present COVID-19 pandemic, lasting for over 1.5 years, has put the health care systems in a challenging situation. Prioritizing other aspects, pain patients have been practically abandoned, probably because Pain Medicine is not perceived as a priority for the patients. The organization of Pain Clinics and the cares for in-hospital pain management is reduced for quantity and quality [1]. This challenging situation has also been victim of some misinformation. One of them was diffused at the very beginning of the pandemic. The use of NSAIDs, and especially of ibuprofen, was accused to be responsible for an increased risk of potential infection by SARS-CoV [2]. The subtle pathophysiologic mechanism behind this was supposed to be the action of ibuprofen on the angiotensin-converting enzyme 2 (ACE2), also involved in the action of coronoviruses. The shocking theory had obvious consequences, especially for its diffusion in the media, but was rejected immediately after [3] and also reviewed by the same authors [4]. Immediately after, other authors have expressed their perplexities on the topic [5]. Then, all the connections between COVID-19 and NSAIDs were summarized in an extensive review article [6]. The one above is just one of the examples of the disastrous consequences of COVID-19 pandemics on the poor patients suffering for pain, both acute and chronic. Other connected problems were related to the organization of the pain clinics and the network for home care for suffering pain patients. All these topics will be illustrated and summarized during the lecture. The congress will be an excellent occasion to also collect opinions and feedbacks of the attending Colleagues.
{"title":"Pain management and COVID-19","authors":"G. Varrassi","doi":"10.22514/sv.2021.200","DOIUrl":"https://doi.org/10.22514/sv.2021.200","url":null,"abstract":"The still present COVID-19 pandemic, lasting for over 1.5 years, has put the health care systems in a challenging situation. Prioritizing other aspects, pain patients have been practically abandoned, probably because Pain Medicine is not perceived as a priority for the patients. The organization of Pain Clinics and the cares for in-hospital pain management is reduced for quantity and quality [1]. This challenging situation has also been victim of some misinformation. One of them was diffused at the very beginning of the pandemic. The use of NSAIDs, and especially of ibuprofen, was accused to be responsible for an increased risk of potential infection by SARS-CoV [2]. The subtle pathophysiologic mechanism behind this was supposed to be the action of ibuprofen on the angiotensin-converting enzyme 2 (ACE2), also involved in the action of coronoviruses. The shocking theory had obvious consequences, especially for its diffusion in the media, but was rejected immediately after [3] and also reviewed by the same authors [4]. Immediately after, other authors have expressed their perplexities on the topic [5]. Then, all the connections between COVID-19 and NSAIDs were summarized in an extensive review article [6]. The one above is just one of the examples of the disastrous consequences of COVID-19 pandemics on the poor patients suffering for pain, both acute and chronic. Other connected problems were related to the organization of the pain clinics and the network for home care for suffering pain patients. All these topics will be illustrated and summarized during the lecture. The congress will be an excellent occasion to also collect opinions and feedbacks of the attending Colleagues.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45308161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction: 21% of patients suffering from fibromyalgia also suffer from bipolar disorder [1] and reversibly 50% of patients with bipolar disorder (BD) suffer from chronic pain syndromes including fibromyalgia [2]. Fibromyalgia and BD seem to share the same pathophysiologic mechanism [3]. The aim of this case report is to emphasize the interrelation of fibromyalgia and BD in order to improve the therapeutic management of those patients. Method: A 45 years old female patient came into the Pain Clinic complaining about exacerbation of fibromyalgic pain for six months. She was receiving venflaxine 300 mg, Aripiprazole 10 mg, gabapentin 1800 mg, mirtazapine 30 mg daily. For analgesia she was taking a combination of paracetamol/ codeine in a daily dose of 4 gr/500 mg respectively and transdermal buprenorphine 70 μcg. Therapeutic interventions with trigger point injections and intra-articular injections on both knees was given. Past medical history: BD type II for 20 years, fibromyalgia for ten years, hypothyroidism. Social history: married with two children. She was working in administration of a public service. Physical examination: neck stiffness, tender points, WPI = 9 and SSS = 7, score on PHQ-9 questionnaire 20/27. Multivariant therapeutic approach: Adjustment of fibromyalgia pharmaceutical therapy. Communication with treating psychiatrist for modification of the therapy for BD. Complementary acupuncture therapy was provided. Evaluation of patient using VAS score and dose of analgesic medication on every session and three months after therapy. Questionnaire PHQ-9 was repeated at the end of therapy and three months afterwards. Results: There was gradual reduction on the intensity of pain. The analgesic therapy was interrupted after the third session. PHQ-9 scored 5/27 at the end of therapy and 7/27 three months later. Conclusions: Fibromyalgia and BD can coexist and the symptoms of one may shadow or worsen the symptoms of the other. Multivariant approach is needed for effective therapy and psychiatric intervention.
{"title":"Approach of the relationship between fibromyalgia and bipolar disorder through an interesting case report","authors":"E. Chainaki, N. Polaki, D. Manoukakis","doi":"10.22514/sv.2021.174","DOIUrl":"https://doi.org/10.22514/sv.2021.174","url":null,"abstract":"Introduction: 21% of patients suffering from fibromyalgia also suffer from bipolar disorder [1] and reversibly 50% of patients with bipolar disorder (BD) suffer from chronic pain syndromes including fibromyalgia [2]. Fibromyalgia and BD seem to share the same pathophysiologic mechanism [3]. The aim of this case report is to emphasize the interrelation of fibromyalgia and BD in order to improve the therapeutic management of those patients. Method: A 45 years old female patient came into the Pain Clinic complaining about exacerbation of fibromyalgic pain for six months. She was receiving venflaxine 300 mg, Aripiprazole 10 mg, gabapentin 1800 mg, mirtazapine 30 mg daily. For analgesia she was taking a combination of paracetamol/ codeine in a daily dose of 4 gr/500 mg respectively and transdermal buprenorphine 70 μcg. Therapeutic interventions with trigger point injections and intra-articular injections on both knees was given. Past medical history: BD type II for 20 years, fibromyalgia for ten years, hypothyroidism. Social history: married with two children. She was working in administration of a public service. Physical examination: neck stiffness, tender points, WPI = 9 and SSS = 7, score on PHQ-9 questionnaire 20/27. Multivariant therapeutic approach: Adjustment of fibromyalgia pharmaceutical therapy. Communication with treating psychiatrist for modification of the therapy for BD. Complementary acupuncture therapy was provided. Evaluation of patient using VAS score and dose of analgesic medication on every session and three months after therapy. Questionnaire PHQ-9 was repeated at the end of therapy and three months afterwards. Results: There was gradual reduction on the intensity of pain. The analgesic therapy was interrupted after the third session. PHQ-9 scored 5/27 at the end of therapy and 7/27 three months later. Conclusions: Fibromyalgia and BD can coexist and the symptoms of one may shadow or worsen the symptoms of the other. Multivariant approach is needed for effective therapy and psychiatric intervention.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48396581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
F. Sifaki, I. Mantzoros, E. Koraki, S. Bagntasarian, P. Christidis, Vaia Tsapara, K. Theodoraki
Introduction: Laparoscopic cholecystectomy (LC), is one of the most common surgeries performed in general surgery. Most of the times, LC is accompanied by moderate to severe postoperative pain. Erector Spinae Plane Block (ESPB) is an innovative trunk block which has been used as a method of postoperative analgesia in various clinical procedures. In this study we evaluated its effectiveness as a method of perioperative analgesia, seeking to investigate whether it is effective in reducing perioperative opioid administration in patients undergoing LC. Methods: This is a double-blind, randomized, controlled, prospective study. 60 patients were randomized into Group C (ESPB with N/S 0.9%), Group D (ESPB with ropivacaine 0.375%, dexmedetomidine 1 γ/kg) and Group R (ESPB with ropivacaine 0.375%). ESPB was performed bilaterally before induction of general anesthesia, with ultrasound guidance. Statistical analysis included ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis and Spearman tests. Results: All patients remained hemodynamically stable during their hospitalization, without major complications. Statistical significance was found to exist regarding total perioperative remifentanil consumption between all three Groups. Median morphine consumption, NRS pain scores and mobilization time of the patients was found to be significantly less in patients of Group D compared with patients of Group C and in patients of Group R compared with patients of Group C. However, there was no statistically important difference between Groups D and R. Satisfaction scores were found to be statistically higher in patients of Group D when compared with patients of Group C. Conclusion: ESPB performance with administration of ropivacaine or a combination of ropivacaine and dexmedetomidine in patients undergoing LC, is an innovative, safe and simple method which contributes to the amelioration of the quality of perioperative analgesia, avoiding the complications arising from opioid administration and thus, achieving multimodal analgesia.
{"title":"The effectiveness of Bilateral Erector Spinae Plane Block in reducing perioperative opioid administration in patients undergoing Laparoscopic Cholecystectomy","authors":"F. Sifaki, I. Mantzoros, E. Koraki, S. Bagntasarian, P. Christidis, Vaia Tsapara, K. Theodoraki","doi":"10.22514/sv.2021.164","DOIUrl":"https://doi.org/10.22514/sv.2021.164","url":null,"abstract":"Introduction: Laparoscopic cholecystectomy (LC), is one of the most common surgeries performed in general surgery. Most of the times, LC is accompanied by moderate to severe postoperative pain. Erector Spinae Plane Block (ESPB) is an innovative trunk block which has been used as a method of postoperative analgesia in various clinical procedures. In this study we evaluated its effectiveness as a method of perioperative analgesia, seeking to investigate whether it is effective in reducing perioperative opioid administration in patients undergoing LC. Methods: This is a double-blind, randomized, controlled, prospective study. 60 patients were randomized into Group C (ESPB with N/S 0.9%), Group D (ESPB with ropivacaine 0.375%, dexmedetomidine 1 γ/kg) and Group R (ESPB with ropivacaine 0.375%). ESPB was performed bilaterally before induction of general anesthesia, with ultrasound guidance. Statistical analysis included ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis and Spearman tests. Results: All patients remained hemodynamically stable during their hospitalization, without major complications. Statistical significance was found to exist regarding total perioperative remifentanil consumption between all three Groups. Median morphine consumption, NRS pain scores and mobilization time of the patients was found to be significantly less in patients of Group D compared with patients of Group C and in patients of Group R compared with patients of Group C. However, there was no statistically important difference between Groups D and R. Satisfaction scores were found to be statistically higher in patients of Group D when compared with patients of Group C. Conclusion: ESPB performance with administration of ropivacaine or a combination of ropivacaine and dexmedetomidine in patients undergoing LC, is an innovative, safe and simple method which contributes to the amelioration of the quality of perioperative analgesia, avoiding the complications arising from opioid administration and thus, achieving multimodal analgesia.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44822260","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Patients with chronic pain and chronic diseases are looking for ways to combat the health implications, to alleviate the side effects of treatments and to improve their quality of life. The medical community is constantly looking for ways to provide the comprehensive health care that patients need. In this context, more pluralistic healthcare systems began to develop, combining conventional and complementary approaches in a coordinated way and to varying degrees. These systems are referred to as Integrative (UK) or Integrated (USA) Medicine. Two dominant models of Integrative Medicine have been developed. The first is a selective combination of Complementary Therapies used as add-on to the treatment proposed by conventional medicine, based on evidence from Research and Practice (Supplementary Model). The second includes only Evidence-Based Complementary Treatments that are integrated in the usual care (Collaborative Model). These two models have different levels of autonomy, control and responsibility among the participating health professionals. Despite their differences, both models focus on the patient and offer a holistic approach. In Greece, a Supplementary Model of Integrated Medicine is offered at the Pain Clinic of Aretaieion Hospital. This model selectively combines various Complementary Treatments such as Reflexology, Shiatsu, Acupuncture, Psychological support, etc., as add-on to the conventional treatments thereby maximizing the beneficial results and can serve as a pioneering example for the development of Integrated Medicine systems in Greece. A well-designed model of Integrated Medicine, combining every possible means and every available treatment and that includes all the necessary safety checks can be particularly effective in achieving the goal of any medical system. The goal of a comprehensive treatment of the disease and its side effects across all aspects of the patient’s life.
{"title":"Integrative medicine models","authors":"S. Raptopoulou","doi":"10.22514/sv.2021.198","DOIUrl":"https://doi.org/10.22514/sv.2021.198","url":null,"abstract":"Patients with chronic pain and chronic diseases are looking for ways to combat the health implications, to alleviate the side effects of treatments and to improve their quality of life. The medical community is constantly looking for ways to provide the comprehensive health care that patients need. In this context, more pluralistic healthcare systems began to develop, combining conventional and complementary approaches in a coordinated way and to varying degrees. These systems are referred to as Integrative (UK) or Integrated (USA) Medicine. Two dominant models of Integrative Medicine have been developed. The first is a selective combination of Complementary Therapies used as add-on to the treatment proposed by conventional medicine, based on evidence from Research and Practice (Supplementary Model). The second includes only Evidence-Based Complementary Treatments that are integrated in the usual care (Collaborative Model). \u0000These two models have different levels of autonomy, control and responsibility among the participating health professionals. Despite their differences, both models focus on the patient and offer a holistic approach. In Greece, a Supplementary Model of Integrated Medicine is offered at the Pain Clinic of Aretaieion Hospital. This model selectively combines various Complementary Treatments such as Reflexology, Shiatsu, Acupuncture, Psychological support, etc., as add-on to the conventional treatments thereby maximizing the beneficial results and can serve as a pioneering example for the development of Integrated Medicine systems in Greece. A well-designed model of Integrated Medicine, combining every possible means and every available treatment and that includes all the necessary safety checks can be particularly effective in achieving the goal of any medical system. The goal of a comprehensive treatment of the disease and its side effects across all aspects of the patient’s life.","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41786937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Spinal anesthesia is considered the anesthetic technique of choice in cesarean section but it can be frequently complicated by hypotension, with occasionally serious consequences for both the mother and fetus. One of the standard techniques used in the prevention of maternal hypotension is the administration of a continuous phenylephrine infusion. However, phenylephrine can lead to baroreceptor-mediated reflex bradycardia with untoward consequences for the maternal cardiac output. Nowadays, noradrenaline has been proposed as an alternative agent in this context, since due to its additional weak dose-dependent β-action, it can be associated with an inferior incidence of maternal bradycardia and thus of propensity to decrease the cardiac output. Colloid co-hydration has also been proven to be an effective technique in the prevention of maternal hypotension. This double-blinded, prospective randomized study aimed to investigate whether the addition of a fixed rate phenylephrine infusion or noradrenaline infusion to a colloid co-hydration regimen results in better maternal hemodynamic status or in a more favorable metabolic profile in the newborn as compared to the administration of colloids alone without any vasoconstrictor during elective cesarean section under combined spinal-epidural anesthesia. Materials and methods: One hundred-twenty parturients were randomized to either phenylephrine 50 μg/min (group P) or noradrenaline 4 μg/min (group N) or placebo (group C). All infusions had been prepared in identical syringes and the infusion rate was 30 mL/h in order to ensure the “blindness” of the study. As soon as the spinal injection started, all groups were administered 10 mL/kg of hydroxyethyl starch (HES) solution simultaneously with the onset of vasoconstrictor infusion. The primary end-point of the study was the incidence of maternal hypotension (SAP <80% of baseline). Additionally, maternal hemodynamics at specific time-points were recorded using non-invasive technology (Edwards Lifesciences ClearSight System) as well as the incidence of reactive hypertension, bradycardia, the requirement for bolus vasoconstrictor administration and the fetal acid-base status, the umbilical venous and arterial blood gases and the newborn Apgar score. Results: The incidence of maternal hypotension was higher in group C than in group P and also higher in group C than in group N (p = 0.024 and 0.073, respectively). The need of bolus administration of vasoconstrictor was higher in group C than in group P and also higher in group C than in group N (p = 0.001 and 0.003, respectively). The incidence of bradycardia was higher in group P than in group N (p = 0.018). The incidence of reactive hypertension was higher in group P than in group N and also higher in group P than in group C (p = 0.029 and 0.005, respectively). The need of modification of the infusion rate was higher in group P than in group N and also higher in group P than in group C (p < 0.001 κα
{"title":"Prevention of hypotension during elective cesarean section with a combination of colloid co-load and a continuous infusion of a vasoconstrictive agent: A comparative randomized study","authors":"Z. Masourou, K. Theodoraki","doi":"10.22514/sv.2021.169","DOIUrl":"https://doi.org/10.22514/sv.2021.169","url":null,"abstract":"Background: Spinal anesthesia is considered the anesthetic technique of choice in cesarean section but it can be frequently complicated by hypotension, with occasionally serious consequences for both the mother and fetus. One of the standard techniques used in the prevention of maternal hypotension is the administration of a continuous phenylephrine infusion. However, phenylephrine can lead to baroreceptor-mediated reflex bradycardia with untoward consequences for the maternal cardiac output. Nowadays, noradrenaline has been proposed as an alternative agent in this context, since due to its additional weak dose-dependent β-action, it can be associated with an inferior incidence of maternal bradycardia and thus of propensity to decrease the cardiac output. Colloid co-hydration has also been proven to be an effective technique in the prevention of maternal hypotension. This double-blinded, prospective randomized study aimed to investigate whether the addition of a fixed rate phenylephrine infusion or noradrenaline infusion to a colloid co-hydration regimen results in better maternal hemodynamic status or in a more favorable metabolic profile in the newborn as compared to the administration of colloids alone without any vasoconstrictor during elective cesarean section under combined spinal-epidural anesthesia. Materials and methods: One hundred-twenty parturients were randomized to either phenylephrine 50 μg/min (group P) or noradrenaline 4 μg/min (group N) or placebo (group C). All infusions had been prepared in identical syringes and the infusion rate was 30 mL/h in order to ensure the “blindness” of the study. As soon as the spinal injection started, all groups were administered 10 mL/kg of hydroxyethyl starch (HES) solution simultaneously with the onset of vasoconstrictor infusion. The primary end-point of the study was the incidence of maternal hypotension (SAP <80% of baseline). Additionally, maternal hemodynamics at specific time-points were recorded using non-invasive technology (Edwards Lifesciences ClearSight System) as well as the incidence of reactive hypertension, bradycardia, the requirement for bolus vasoconstrictor administration and the fetal acid-base status, the umbilical venous and arterial blood gases and the newborn Apgar score. Results: The incidence of maternal hypotension was higher in group C than in group P and also higher in group C than in group N (p = 0.024 and 0.073, respectively). The need of bolus administration of vasoconstrictor was higher in group C than in group P and also higher in group C than in group N (p = 0.001 and 0.003, respectively). The incidence of bradycardia was higher in group P than in group N (p = 0.018). The incidence of reactive hypertension was higher in group P than in group N and also higher in group P than in group C (p = 0.029 and 0.005, respectively). The need of modification of the infusion rate was higher in group P than in group N and also higher in group P than in group C (p < 0.001 κα","PeriodicalId":49522,"journal":{"name":"Signa Vitae","volume":" ","pages":""},"PeriodicalIF":1.1,"publicationDate":"2021-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43254144","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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