Techniques in regional anesthesia & pain management最新文献

It has been well known for years that there is considerable interindividual variability in the sensitivity to and tolerance of experimental pain stimuli, in the propensity to develop painful pathologies, and in the response to analgesic therapies; however, this does not mean that such differences are because of genetic factors alone, as pain is a complex phonemenon in which psychological and environmental factors, for example, as well as those inherent to physiological mechanisms, play an important role. Several different methods are used in genetic pain research. Although the identification of mutations can explain some very infrequent pathologies that follow Mendelian patterns of inheritance, the research method used in most cases is the genetic association study, which tests the correlation between a certain phenoytpe (pain) and a polymorphism or single-nucleotide polymorphism. At present there is evidence suggesting that genetic factors may be at least partially responsible for the greater pain experienced by certain individuals following an acute injury, such as a surgical intervention; however, studies analyzing the influence of genetics on chronic postsurgical pain have been scarce.

The existence of opioid-induced hyperalgesia (OIH), ie, nociceptive sensitization, caused by exposure to opioids remains difficult to appraise in perioperative setting because objective assessment is rare, evidence mostly relying on subjective measures like pain scores and postoperative analgesics use. Basic diagnostic criteria of OIH are still needed. Experimental studies have highlighted the pronociceptive effects of intraoperative high doses of opioids in term of latent hypersensitivity and long-term vulnerability to pain. The real question in daily clinical practice is then whether OIH prevention matters and which patients might be concerned. Until recently, OIH has been associated to intraoperative administration of high doses of opioids, mainly remifentanil, which increases acute postoperative pain and perhaps might cause the persistence of postsurgical pain. Recently, the existence of preoperative OIH has been demonstrated in chronic pain patients under chronic opioids intake and its exacerbation by the administration of intraoperative opioids has been suggested. Finally, the effect of long-term postoperative opioids intake on pain persistence after surgery or trauma certainly deserves to be questioned. Thereby, the prevention of perioperative OIH should extend up to several weeks after surgery and should include chronic postsurgical pain. The later point argues for the development of dedicated chronic postsurgical pain services.

The management of postoperative pain should not only focus on the surgery procedure. Taking into account of many parameters that can change the course of the perioperative pain; an early preoperative anesthesia management should allow to improve various protocols. Some factors can be greatly improved during the preoperative period; others parameters can be modified by the protocol during or after the surgery.

Chronification of acute postoperative pain is the consequence of a number of factors; the article mentions different preemptive strategies that may put a limit to its development. Certain anesthetic and analgesic techniques have been assessed over the last years, and most articles highlight the usefulness of carrying out regional anesthesia techniques from the intraoperative period through several days into the postoperative period. Preventing the patients from suffering acute postoperative pain is one of the most appropriate tools for stopping the activation of the mechanisms involved in pain chronification. None of the regional techniques are equally valid and applicable to all surgical procedures.

Vertebral fractures are very common. The estimated annual incidence is 1.4 million cases worldwide—the most frequent underlying cause being osteoporosis. The first-line treatment for symptomatic Vertebral fractures is generally conservative and is based on analgesics, rest, orthesis, and rehabilitation. However, up to one-third of all patients fail to respond to such treatment and require surgery. In the last 20 years, 2 safe and effective minimally invasive procedures have been developed as an alternative to conservative management and open surgery: vertebroplasty and kyphoplasty. The complications of both these techniques, although infrequent, are not negligible and include infection, bleeding, worsening of the pain, radiculopathy, canal stenosis, local trauma, and embolisms. Most complications are directly or indirectly related to cement injection—the most common problem being cement leakage from the vertebral body not only into the intervertebral space but also into the spinal canal. Pulmonary embolization may even occur. The present study describes the most common complications during treatment and the ways to improve the technique and procedures, with a view to avoiding such problems.

Spinal cord stimulation has become one of the mainstays of chronic treatment for patients in pain units. It is a safe, effective, and reversible technique, although the rate of complications is approximately 30%-40%. The most common complication, despite technological breakthroughs and advances in equipment, continues to be electrode migration, which currently occurs in approximately 13% of cases. The most serious complication is related to neurologic problems after infections in the epidural space. A review of technique-related complications is performed, classifying them into mechanical and biological complications, including the strategies to avoid them, mainly through careful patient selection, correct surgical technique, and good selection of the programmed electrical parameters.

Interventional pain management is a specialty that uses invasive procedures to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving exogenous anticoagulants and antithrombotics. Even though the risk of major bleeding is very small, the consequences can be catastrophic. However, the role of antithrombotic therapy for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events is also crucial.

Epiduroscopy is a minimally invasive diagnostic and therapeutic technique that was introduced in clinical practice in early 1990s. We have performed a systematic review of side effects and complications reported in literature. Troubleshooting to prevent or reduce complications has been proposed. Dural puncture and fluid injection overpressure were the main causes of complications. According to the published evidence, conventional epiduroscopy is a safe procedure with no mortality and little morbidity.

Complications of pain medicine practice are common. Interventional techniques carry significant complications and risks. There is evidence that avoiding distressed or angry patients is associated with better outcomes, fewer complaints, and lower rates of litigation. Being respectful and pleasant with patients and communicating with them lead to lower rates of complaints and litigation. The empathy in the medical-patient relationship can avoid, in many cases, the demands for negligence. Informed consent must be obtained for each of the pain unit interventional techniques to adequately cover 2 crucial requirements: correct patient information and patient participation in the decision-making process. Documentation of written informed consent must be witnessed and documented in the patient’s record. Recognition and information of malpractice is something necessary. There is evidence that a sincere excuse can reduce the incident of litigations. A reporting system for adverse events and patient safety failures in relation to interventional techniques used in the treatment of pain (American Society of Anesthesiologists Closed Claims Analysis, American Society of Interventional Pain Physicians (ASSIP), and Spanish Notification System Security of Anesthesia and Resuscitation (SENSAR)) is important. Maintaining a dialogue with the patient or patient’s family or both after malpractice is important as is keeping the patient coming for follow-up, which allows the physician to maintain continuity of care.