Techniques in regional anesthesia & pain management最新文献

Acute and chronic pain conditions are an inescapable by-product of the conduct of war, and have been so throughout the recorded history. The field of pain management within the war zone has evolved during the Global War on Terrorism, spurred in part by increased survival rates from improved vehicle and personal armor, improved surgical lifesaving techniques and hastened evacuation. A result of these improvements is that wounds that were once fatal are now survivable, but may be a cause for significant pain. In this article, we discuss acute and chronic pain management during war, and describe important changes that have occurred during the course of the Global War on Terrorism. Advances in acute pain treatment include multimodal pain regimens from point of injury through air transport from theater. The role of technologies, such as nerve stimulation, ultrasound imaging, and medication pumps, suitable for field use is explored. Chronic pain interventions that have been provided in theater are discussed, as well as the effect that early treatment in theater has on return-to-duty rates. An increasing operational effect from pain management is postulated as military forces become smaller, more specialized, and older.

Spinal cord injury is a devastating occurence, an event that alters patients' lives and their families. Individuals with spinal cord injury often have chronic pain. The aim is to present a course with management measures that should be taken at the time of appearance of pain, acute, chronic or both, a multimodal management approach according to pathophysiology, taking into account that its treatment remains unsatisfactory. Also consider involving cognitive, emotional, and social issues for a comprehensive approach to patient with spinal cord injury.

Owing to advanced protective technologies, many servicemembers are returning home with injuries that proved fatal in previous conflicts. However, such severe injuries provide numerous challenges for acute pain physicians. Advanced regional anesthetic techniques provide an essential multimodal tool that optimizes pain and minimizes opioid use. Utilization of such techniques in current conflicts has progressed from a rare occurrence owing to limited equipment and personnel to a widely use array of techniques utilized on the battlefield and continued throughout transport stateside. Such an evolution has enhanced the development of acute pain medicine services within the military that deliver such techniques along with noninterventional techniques. Further, such acute pain medicine services are well received in a combat theater and may serve as an optimal model in future conflicts. Preliminary experience within the last decade has described the interplay of such techniques with anticoagulation regimens in such trauma patients, incidence of infection, levels of serum local anesthetics in patients with multiple catheters, and the utility of such techniques in patients who may be at risk for compartment syndrome but must bear with a long transport chain back home. Looking forward, future training of personnel and tracking of outcomes are essential in optimizing the utility of such techniques in forward environments, but the collection of accurate outcome data will also determine if prolonged benefits can be realized in addition to the obvious benefit downrange.

Chronic pain has been long recognized as a stressor that can precipitate anxiety symptoms. Research has recently focused on the prevalence and role of pain-related posttraumatic stress disorder (PTSD). Rates of chronic pain among those diagnosed with PTSD are unexpectedly high, and it is still unknown why pain and PTSD symptoms coexist. Yet, different physiological, psychological, and behavioral mechanisms could explain the association between both disorders. PTSD is a disorder that requires the exposure to a traumatic event and is characterized by avoidance, re-experiencing, and increased physiological arousal. Psychological and neurobiological interacting factors are responsible for the occurrence and maintenance of PTSD and, thus, they should be considered when understanding the relationship between PTSD and chronic pain. In the present review, aspects related to PTSD diagnosis and detection are discussed in the context of chronic pain, as well as its risk factors and management.

Neurostimulation has been one of the most significant advances in the field of regional anesthesia. Knowledge of its technical details is still growing, and new clinical and research work on the subject is continually being published. The introduction of ultrasonography as an instrument for identifying peripheral nerves has been a true revolution and seems to be competing with neurostimulation. Most of the articles on the subject compare these 2 location methods; however they are compatible with and complementary of each other. There is some controversy about the advantages of combining both methods, and further trials are required to determine those advantages. Safety, however, increases when more than 1 system is involved. The financial cost is not high and could be absorbed if its benefits are proven. This article reviews the bases of neurostimulation and proposes new ways of using it, based both on the clinical practice and on the latest research published.

One of the advantages attributed to the use of ultrasounds in regional anesthesia is the possibility of applying low volumes of local anesthetic. Some studies report the efficient use of extremely low volumes in certain types of blocks. Those results are not easy to extrapolate to general practice because of, among other reasons, the big differences in technical skills among professionals (which are crucial to the ability to reduce the volume used). However, the term “intraneural injection” is currently being redefined based on histology, anatomy, physiology, and on clinical and experimental results. The possibility and advisability of using intraneural-extrafascicular injections to obtain efficient and safe blocks with minimum volumes is now widely studied and debated, as well as the idea that it could be safe in certain selected locations (mainly at the popliteal sciatic level). The purpose of this article is to present the current status of this topic and to share our opinion and elicit debate on the true repercussions and usefulness of a hypothetical reduction of the local anesthetic volumes to their minimum, based on both the reports published and our own clinical experience.

The use of ultrasound in regional anesthesia techniques has aroused much interest during the past decade. Ultrasound has allowed the development of the classic regional techniques described by landmark references, neurostimulation guide, loss of resistant technique, or “click” and “pop” methods. Ultrasound application to anesthesiology has enabled not only to directly monitor the procedures already described but also to report new techniques. Because some of those techniques are a novelty and the literature on them is sparse, the purpose of this article is to provide information on the most recent ultrasound-guided techniques by reviewing the literature and giving practical advice for patient management according to our own experience.

Currently, the most commonly used techniques to perform peripheral nerve blockade are ultrasound-guided regional anesthesia (UGRA) and nerve stimulation (NS). Since its introduction in the 1990s, the use of ultrasound has gained popularity. In the beginning, it was used together with NS to confirm identification of nerve structures, once the learning curve has reached its end, there is a trend to use UGRA alone. In this article, we discuss the pros and cons of performing RA procedures with NS, UGRA, or a combination of both, which we call stimulated and ultrasound-guided regional anesthesia (SUGRA). Even though the use of SUGRA does not seem to improve the success rate of the nerve blocks, does not shorten the time to perform them, and does not shorten the onset time, it does help to avoid intraneural injection without increasing patient's discomfort. The use of SUGRA with low-intensity current and without a generation of motor response, would allow positioning of the needle tip close to the nerve avoiding intraneural injection and nerve damage.

Severe postoperative pain and wound hyperalgesia, a clinical sign of central sensitization, are risk factors for the development of chronic postsurgical pain. This article describes the neuronal changes that surgical pain and possibly high opioid doses cause in the central nervous system. It also relates how regional anesthesia might oppose these changes and block both the pain sensitization and the pain chronification following surgery.