Lignocaine is an essential drug on World Health Organisation essential drug list, considered efficacious, safe and cost-effective for any health-care system. Despite its ubiquitous use in medicine and surgery, there a...Lignocaine is an essential drug on World Health Organisation essential drug list, considered efficacious, safe and cost-effective for any health-care system. Despite its ubiquitous use in medicine and surgery, there are few detailed reviews of its pharmacokinetics and pharmacodynamics. Being an amide-type local anesthetic and Class 1b antiarrhythmic, lignocaine is most frequently used clinically for its anesthetic and antiarrhythmic benefits. However, lignocaine has important antinociceptive, immuno-modulating, and antiinflammatory properties. Information pertaining to the pharmacokinetics and pharmacodynamics of lignocaine was examined by performing a literature search of Pub Med, Embase and MEDLINE(via Ovid), pharmacology textbooks and online sources. We present a focused synopsis of lignocaine's pharmacological composition, indications for use and mechanisms of action, focusing on its anti-inflammatory, immuno-modulating and analgesia effects. In addition we review the dosing regimes and infusion kinetics of lignocaine in the clinical setting. Finally, we review the evidence for ligocaine's modulation of the inflammatory response during major surgery and its specific effects on cancer recurrence. These indirect effects of local anesthetics in tumor development may stem from the reduction of neuroendocrine responses to the stress response elicited by major surgery and tissue damage, enhanced preservation of immune-competence, in addition to opioid-sparing effects of modulating tumor growth.展开更多
BACKGROUND Osteonecrosis or avascular necrosis(AVN)of the hip was one of the dreaded complications of coronavirus disease 2019(COVID-19),which emerged in patients who received steroid therapy.Corticosteroids have been...BACKGROUND Osteonecrosis or avascular necrosis(AVN)of the hip was one of the dreaded complications of coronavirus disease 2019(COVID-19),which emerged in patients who received steroid therapy.Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients.Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous(IV)or oral dexamethasone,methylprednisolone or hydrocortisone.The use of such high doses of corticost-eroids has shown very positive results and has been lifesaving in many cases.Still,long-term consequences were drug-induced diabetes,osteoporosis,Cushing syndrome,muscle wasting,peripheral fat mobilization,AVN,hirsutism,sleep disturbances and poor wound healing.A significant number of young patients were admitted for bilateral total hip replacements(THR)secondary to AVN following steroid use for COVID-19 treatment.AIM To assess the efficacy of bilateral pericapsular end nerve group(PENG)blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.METHODS This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals,Hyderabad,India.Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months.All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.RESULTS The duration of surgery was 2.5 h on average.Seventeen out of twenty patients(85%)had a Visual Analog Score(VAS)of less than 2 and did not require any supplementation.One patient was removed from the study,as he required re-exploration.The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug.Fifteen out of seventeen patients(88.2%)could be mobilized 12 h after the procedure.CONCLUSION Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19,which surfaced in patients who received steroid展开更多
BACKGROUND Malignant hyperthermia(MH)is a hypermetabolic disorder of skeletal muscles triggered by exposure to volatile anesthetics and depolarizing muscular relaxants.It manifests with clinical presentations such as ...BACKGROUND Malignant hyperthermia(MH)is a hypermetabolic disorder of skeletal muscles triggered by exposure to volatile anesthetics and depolarizing muscular relaxants.It manifests with clinical presentations such as tachycardia,muscle rigidity,hyperpyrexia,and rhabdomyolysis in genetically predisposed individuals with ryanodine receptor or calcium voltage-gated channel subunit alpha1 S mutations.Local anesthetics,such as lidocaine,are generally considered safe;however,complications can arise,albeit rarely.Lidocaine administration has been reported to induce hypermetabolic reactions resembling MH in susceptible individuals.The exact mechanism by which lidocaine might trigger MH is not fully understood.Although some mechanisms are postulated,further research is needed for a better understanding of this.CASE SUMMARY We present the case of MH in a 43-year-old male patient with an unknown genetic predisposition following a lidocaine injection during a dental procedure.This case serves as a reminder that while the occurrence of lidocaine-induced MH is rare,lidocaine can still trigger this life-threatening condition.Therefore,caution should be exercised when administering lidocaine to individuals who may be susceptible to MH.It is important to note that prompt intervention played a crucial role in managing the patient’s symptoms.Upon recognizing the early signs of MH,aggressive measures were initiated,including vigorous intravenous normal saline administration and lorazepam.Due to the effectiveness of these interventions,the administration of dantrolene sodium,a specific antidote for MH,was deferred.CONCLUSION This case highlighted the significance of vigilant monitoring and swift action in mitigating the detrimental effects of lidocaine-induced MH.Caution should be exercised when administering lidocaine to individuals who may be predisposed to MH.It is very important to be aware and vigilant of the signs and symptoms of MH as early recognition and treatment intervention are important to prevent serious complications展开更多
Lumbar radiculopathy, a group of diseases in which the dorsal root ganglia(DRG) or dorsal roots are adversely affected by herniated discs or spinal stenosis, are clinically characterized by spontaneous and evoked type...Lumbar radiculopathy, a group of diseases in which the dorsal root ganglia(DRG) or dorsal roots are adversely affected by herniated discs or spinal stenosis, are clinically characterized by spontaneous and evoked types of pain. The pain is underpinned by various distinct pathophysiological mechanisms in the peripheral and central nervous systems. However, the diagnosis of lumbar radiculopathy is still unsatisfactory, because the association of the pain with the neurobiological basis of radiculopathy is largely unknown. Several animal models used to explore the underlying neurobiological basis of lumbar radiculopathy could be classified as mechanical, chemical, or both based on the component of injury. Mechanical injury elevates the intraneural pressure, reduces blood flow, and eventually establishes ischemia in the dorsal root and the DRG. Ischemia may induce ischemic pain and cause nerve damage or death, and the subsequent nerve damage or death may induce neuropathic pain. Chemical injury predominately induces inflammation surrounding the dorsal roots or DRG and consequent inflammatory mediators cause inflammatory pain. Furthermore, DRG neurons sensitized by inflammatory mediators are hypersensitive to innocuous mechanical force(stretch or compression) and responsible for mechanical allodynia in radiculopathy. As well, central sensitization in the spinal cord may play an important role in pain generation in lumbar radiculopathy. Increasing knowledge of pain-generating mechanisms and their translation into clinical symptoms and signs might allow for dissecting the mechanisms that operate in each patient. With precise clinical phenotypic characterization of lumbar radiculopathy and its connection to a specific underlying mechanism, we should be able to design optimal treatments for individuals. This review discusses the present knowledge of lumbar radiculopathy and proposes a novel mechanism-based classification.展开更多
Dexmedetomidine is a central alpha2-adrenergic receptor agonist with sedative and analgesic properties that has a proven safety profile. It has several beneficial effects such as decreasing sympathetic tone, leading t...Dexmedetomidine is a central alpha2-adrenergic receptor agonist with sedative and analgesic properties that has a proven safety profile. It has several beneficial effects such as decreasing sympathetic tone, leading to reduced opiate use and anxiolysis, making it an attractive option for sedation in the perioperative and intensive care unit setting. These effects also modify favorably the time spent on a ventilator, intensive care unit length of stay and development of delirium. Recent studies also suggest that dexmedetomidine possesses wide-ranging immunomodulating properties. It has been associated with reduced inflammatory cytokine release, modulation of inflammatory transcription factors, oxidative stress and inflammatory cells. These properties could be beneficial in the context of inflammatory conditions that require sedation, such as sepsis, ischemia-reperfusion injury and ventilator-associated lung injury, among many others. In this review, we propose specific clinical scenarios where these properties could turn out to be clinically relevant.展开更多
Preeclampsia is a pregnancy specific syndrome of elusive etiology, developing in 2nd trimester and associated with high maternal and perinatal morbidity and mortality. The spectrum ranges from mild preeclampsia with n...Preeclampsia is a pregnancy specific syndrome of elusive etiology, developing in 2nd trimester and associated with high maternal and perinatal morbidity and mortality. The spectrum ranges from mild preeclampsia with no systemic involvement to multi-system involvement. The course is unpredictable and delivery is the only curative treatment. Elevated blood pressure(> 160/110 mm Hg) should be reduced gradually to a safe level(140/90) using antihypertensive drugs. Prophylaxis and treatment of convulsions using Mg SO4 is indicated for severe preeclampsia. Fluid therapy is controversial due to potential delicate balance between constricted plasma volume and risk of fluid overload and pulmonary oedema secondary to increased capillary permeability and reduced colloid osmotic pressure. Single shot spinal anaesthesia is the technique of choice for caesarean delivery unless contraindicated. General anaesthesia is indicated in patients with coagulopathy or eclampsia but is associated with risk of difficult airway and exaggerated sympathetic response during laryngoscopy. Epidural analgesia and anaesthesia is safe in absence of coagulopathy.展开更多
Pigs are one of most common animal species to be used in biomedical models due to their many anatomical visceral similarities with humans, particularly with regards to transplantation. Despite this use, in many of the...Pigs are one of most common animal species to be used in biomedical models due to their many anatomical visceral similarities with humans, particularly with regards to transplantation. Despite this use, in many of the researches in which pigs are selected for transplantation, the anaesthesia used is an adaptation of human anaes-thesia and presents some limitations such as a reduced analgesia a limited control in perioperative period. In this review we show some of the most important conditions in the preanaesthetic management and of swine as well as we review of anaesthetic protocols for the most common types of swine model of transplantation.展开更多
This review focuses on the mechanisms involved in hepatic ischemia-reperfusion(I/R) injury and effective therapeutic treatments associated with clinical anesthesia. Although hepatocytes are the main target cells in th...This review focuses on the mechanisms involved in hepatic ischemia-reperfusion(I/R) injury and effective therapeutic treatments associated with clinical anesthesia. Although hepatocytes are the main target cells in the whole process of I/R injury, Kupffer cells, as an initiator of harmful cascades, may play a vital role by releasing some proinflammatory mediators and reactive oxygen species in the early phase of I/R injury. The subsequent activation and recruitment of neutrophils are also involved in inflammatory response and immune activation. According to the above mechanisms, a number of strategies have been put forward in some experimental and clinical studies. Most of these therapeutic treatments originated from the generation of oxygen radicals and cytokines, the infiltration of neutrophils, the impairment of microcirculation and so on. Furthermore, increasing evidence has suggested that short periods of ischemic preconditioning have protective effects against liver I/R injury. Depending on these investigations, pharmacological preconditioning and clinical anesthesia-related effective methods have been proposed. A better understanding of the present progress on experimental statistics will bring about novel therapeutic treatments for the improvement of liver surgeries and transplantation.展开更多
Phantom limb pain(PLP) is not uncommon after amputation. PLP is described as a painful sensation perceived in the missing limb. Despite of its complicated pathophysiology, high prevalence of PLP has been associated wi...Phantom limb pain(PLP) is not uncommon after amputation. PLP is described as a painful sensation perceived in the missing limb. Despite of its complicated pathophysiology, high prevalence of PLP has been associated with poor health-related quality of life, low daily activity and short walking distances. A prompt and effective management of PLP is essential in caring for the amputee population. Current treatments including physical therapy, psychotherapy, medications, and interventions have been used with limited success. In this review,we provided an updated and evidence-based review of treatment options for PLP.展开更多
Lung injury can arise during or after anesthesia and can lead to a complicated postoperative course with great implications for the patient. Unfortunately, treatment of acute lung injury is at the moment mainly suppor...Lung injury can arise during or after anesthesia and can lead to a complicated postoperative course with great implications for the patient. Unfortunately, treatment of acute lung injury is at the moment mainly supportive and rates of recovery have not really improved in the recent years. In many cases, lung injury can be anticipated and preventive measures seem possible. This represents a unique challenge to the anesthesiologist, as some new opportunities to reduce the frequency and/or severity of lung injury seem now available. These chances may arise from the potency of preconditioning the lungs before the main injury, with smaller injurious insults. Although preconditioning began to be applicated first on the myocardium, experimental studies have shown potentially beneficial results also for the lungs. This review summarizes the main methods of lung preconditioning that have been tried in experimental studies in the literature and the main mechanisms that are perhaps involved. Emphasis is given in the two main methods of preconditioning that seem readily applicable in the clinical praxis, that is ischemic preconditioning, as well as preconditioning with volatile anesthetics. The few, but interesting clinical studies are also summarized and the future research points in this evolving field of anesthesia are stressed.展开更多
The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we p...The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal(IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, costeffective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.展开更多
Postoperative urinary retention(POUR) is one of the postoperative complications which is often underestimated and often gets missed and causes lot of discomfort to the patient. POUR is essentially the inability to voi...Postoperative urinary retention(POUR) is one of the postoperative complications which is often underestimated and often gets missed and causes lot of discomfort to the patient. POUR is essentially the inability to void despite a full bladder in the postoperative period. The reported incidence varies for the wide range of 5%-70%. Multiple factors and etiology have been reported for occurrence of POUR and these depend on the type of anaesthesia, type and duration of surgery,underlying comorbidities, and drugs used in perioperative period. Untreated POUR can lead to significant morbidities such as prolongation of the hospital stay, urinary tract infection, detrusor muscle dysfunction, delirium, cardiac arrhythmias etc. This has led to an increasing focus on early detection of POUR.This review of literature aims at understanding the normal physiology of micturition, POUR and its predisposing factors, complications, diagnosis and management with special emphasis on the role of ultrasound in POUR.展开更多
AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwe...AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009("pre-VL" group) and over the same 2-mo period after the introduction of VLs in 2012("postVL" group). Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually(P = 0.1768), it showed a trend toward significance when covariates were accounted for(P = 0.0910). Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity(larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender(P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score(P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.展开更多
Foreign body aspiration is a worldwide health problem which often results in life threatening complications. Tracheostomy tube fracture resulting in airway obstruction is a serious condition which has been reported in...Foreign body aspiration is a worldwide health problem which often results in life threatening complications. Tracheostomy tube fracture resulting in airway obstruction is a serious condition which has been reported in the medical literature. We report a rare case of a tracheostomy obturator fractured and lodged in tracheobronchial tree in a patient who presented with acute respiratory distress. Rigid or flexible bronchoscopy is frequently necessary for the diagnosis as well as the treatment. In adults, removal of the foreign body can be attempted during a diagnostic examination with a fiberoptic bronchoscope under lignocaine local infiltration with sedation, which may help to avoid any further invasive procedures. Flexible bronchoscopy should always be considered in foreign body aspiration. A periodic review of the techniques of tracheostomy care, including timely check-ups for signs of wear and tear, can possibly eliminate such avoidable late complications.展开更多
In this review article, we describe a social-signaling perspective of human pain and pain empathizing behaviors which is based on the premise that pain percepts evolved to serve both intrapersonal as well as interpers...In this review article, we describe a social-signaling perspective of human pain and pain empathizing behaviors which is based on the premise that pain percepts evolved to serve both intrapersonal as well as interpersonal, communicative functions. This perspective offers a generative framework for understanding the natural origin and proximate expression of felt pain and pain empathizing behaviors. The basic thesis is that humans evolved sensory-behavioral heuristics for perceiving and inhibiting exogenous and endogenous pain sensations as part of more general expressive styles characterized by the demonstration of vulnerability gestures(i.e., trustworthiness cues) versus empowerment gestures(i.e., capacity cues), and these styles ultimately facilitate broader selfprotection and social novelty-seeking life-history behavior strategies, respectively. We review the extant literature on how social contextual factors(e.g., audience characteristics) and how structural and functional components of individual's social network appear to influence the expression of pain behaviors in ways that support basic predictions from the social-signaling perspective. We also show how the perspective can be used to interpret conventional findings of sex differences in pain percepts and pain empathizing behaviors and for predicting how the situational context and individual's peer networks modulate these differences in vitro and in vitro. We conclude the article by describing how pain researchers may better understand how varying levels and divergent directions of changes in affect tend to co-occur with systematic changes in internal vs external pain sensitivities, and thus why, from an evolutionary perspective, pain may occur in the presence and absence of physical tissue damage.展开更多
Dexmedetomidine is indicated as a sedative agent in intensive care units(ICUs). While several clinical trials and two meta-analyses have compared this agent with propofol or midazolam, the results were variable depend...Dexmedetomidine is indicated as a sedative agent in intensive care units(ICUs). While several clinical trials and two meta-analyses have compared this agent with propofol or midazolam, the results were variable depending on the specific end-point(e.g., duration of mechanical ventilation, ICU mortality, maintaining a target depth of sedation, incidence of delirium episodes, length of hospital stay). Hence, the effectiveness of this new agent vs the comparators seems to be controversial. Trial sequential analysis(TSA) is a statistical technique that can estimate the optimal, cumulative number of patients that would be needed to generate a conclusive result. We therefore applied a TSA model to the most recent meta-analysis evaluating dexmedetomidine. A total of 10 randomized controlled trials were included in our analysis. According to our results, the comparison of dexmedetomidine vs propofol showed no proof of incremental effectiveness for the end-points of length of ICUs stay and incidence of delirium episodes. In contrast, futility(i.e., proof of no incremental effectiveness) was demonstrated for the end-point of mechanical ventilation. Hence, the results for the comparison of dexmedetomidine vs propofol were inconclusive for the first two end-points; on the other hand, conclusiveness was reached for the third end-point. We conclude that the place of dexmedetomidine in therapy of critically ill patients is very uncertain and further controlled trials are still needed.展开更多
AIM: To compare the effectiveness and tolerability of paroxetine vs pregabalin for the management of multiple sclerosis(MS)-induced neuropathic pain(NPP).METHODS: A randomized, flexible-dose open-label 8-wk study invo...AIM: To compare the effectiveness and tolerability of paroxetine vs pregabalin for the management of multiple sclerosis(MS)-induced neuropathic pain(NPP).METHODS: A randomized, flexible-dose open-label 8-wk study involving 21 relapsing-remitting MS patients with MS-induced NPP was conducted to evaluate the effectiveness and tolerability of pregabalin versus paroxetine for pain management. The trial included a 3-wk dose titration phase followed by a 5-wk stable dose phase. Primary outcome measures included daily patient-reported pain intensity as measured using a 100 mm visual analogue scale(VAS pain) and daily impact of pain on daily activities(VAS impact). Hierarchical regression modeling was conducted on each outcome to determine if within person VAS trajectory for pain and impact differed across study groups, during 56 d follow-up. RESULTS: Attrition rates were significantly greater(P < 0.001) in the paroxetine versus pregabalin study group(70% vs 18.2%, respectively). Average study duration between study groups also significantly differed(P < 0.001). Paroxetine participants completed an average of 27.3 d of treatment vs 49.5 d in the pregabalin group, with the majority of patients withdrawing due to adverse events. Due to the high attrition rates in the paroxetine study arm, the investigators stopped the study prior to achieving complete recruitment. As such, no significant differences between pregabalin and paroxetine study arms were noted for the primary outcome measures(VAS pain, VAS impact). Comparative assessment of baseline patient characteristics also revealed no significant differences between the study arms. CONCLUSION: High attrition rates associated with paroxetine use suggest that it be used with caution for MS-induced NPP. Efficacy outcomes could not be assessed due to attrition.展开更多
The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The join...The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can causepain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain(10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks(MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.展开更多
BACKGROUND Heart failure is generally regarded as a progressive and irreversible medical condition.The EVAHEART is an implantable left ventricular assist system.CASE SUMMARY We report the anesthesia management of a 56...BACKGROUND Heart failure is generally regarded as a progressive and irreversible medical condition.The EVAHEART is an implantable left ventricular assist system.CASE SUMMARY We report the anesthesia management of a 56-year-old male patient with dilated cardiomyopathy undergoing an EVAHEART implantation.Transesophageal echocardiography is crucial to ensure the correct positioning of the device and the proper aortic valve outflow.Because the continuous blood flow device functions best under low systemic and pulmonary vascular resistance,milrinone is the preferred drug.Our patient was accompanied by pulmonary hypertension,so during the operation,nitric oxide was used to reduce pulmonary artery pressure.CONCLUSION The cardiac output achieved by the patient with the assistance of EVAHEART can reach 4 L/min,which of course depends on the front load,rear load,and pump speed.展开更多
Using acupuncture instead of anesthetics to induce analgesia was performed in China many years ago in surgical anesthetization. Although many medical units in China's cities and rural areas are applying these tech...Using acupuncture instead of anesthetics to induce analgesia was performed in China many years ago in surgical anesthetization. Although many medical units in China's cities and rural areas are applying these techniques in operations, it should be pointed out that acupuncture anesthesia is still in the process of development and is of next to no practical and even less scientific value in the western world. However, acupuncture-assisted anesthesia can be useful also in countries other than China.展开更多
文摘Lignocaine is an essential drug on World Health Organisation essential drug list, considered efficacious, safe and cost-effective for any health-care system. Despite its ubiquitous use in medicine and surgery, there are few detailed reviews of its pharmacokinetics and pharmacodynamics. Being an amide-type local anesthetic and Class 1b antiarrhythmic, lignocaine is most frequently used clinically for its anesthetic and antiarrhythmic benefits. However, lignocaine has important antinociceptive, immuno-modulating, and antiinflammatory properties. Information pertaining to the pharmacokinetics and pharmacodynamics of lignocaine was examined by performing a literature search of Pub Med, Embase and MEDLINE(via Ovid), pharmacology textbooks and online sources. We present a focused synopsis of lignocaine's pharmacological composition, indications for use and mechanisms of action, focusing on its anti-inflammatory, immuno-modulating and analgesia effects. In addition we review the dosing regimes and infusion kinetics of lignocaine in the clinical setting. Finally, we review the evidence for ligocaine's modulation of the inflammatory response during major surgery and its specific effects on cancer recurrence. These indirect effects of local anesthetics in tumor development may stem from the reduction of neuroendocrine responses to the stress response elicited by major surgery and tissue damage, enhanced preservation of immune-competence, in addition to opioid-sparing effects of modulating tumor growth.
文摘BACKGROUND Osteonecrosis or avascular necrosis(AVN)of the hip was one of the dreaded complications of coronavirus disease 2019(COVID-19),which emerged in patients who received steroid therapy.Corticosteroids have been a mainstay in the treatment protocol of COVID-19 patients.Popular corticosteroid drugs used in patients suffering from COVID-19 were intravenous(IV)or oral dexamethasone,methylprednisolone or hydrocortisone.The use of such high doses of corticost-eroids has shown very positive results and has been lifesaving in many cases.Still,long-term consequences were drug-induced diabetes,osteoporosis,Cushing syndrome,muscle wasting,peripheral fat mobilization,AVN,hirsutism,sleep disturbances and poor wound healing.A significant number of young patients were admitted for bilateral total hip replacements(THR)secondary to AVN following steroid use for COVID-19 treatment.AIM To assess the efficacy of bilateral pericapsular end nerve group(PENG)blocks in patients posted for bilateral THR post-steroid therapy after COVID-19 infection and assess the time taken to first ambulate after surgery.METHODS This prospective observational study was conducted between January 2023 and August 2023 at Care Hospitals,Hyderabad,India.Twenty young patients 30-35 years of age who underwent bilateral THR were studied after due consent over 8 months.All the patients received spinal anaesthesia for surgery and bilateral PENG blocks for postoperative analgesia.RESULTS The duration of surgery was 2.5 h on average.Seventeen out of twenty patients(85%)had a Visual Analog Score(VAS)of less than 2 and did not require any supplementation.One patient was removed from the study,as he required re-exploration.The remaining two patients had a VAS of more than 8 and received IV morphine post-operatively as a rescue analgesic drug.Fifteen out of seventeen patients(88.2%)could be mobilized 12 h after the procedure.CONCLUSION Osteonecrosis or AVN of the hip was one of the dreaded complications of COVID-19,which surfaced in patients who received steroid
文摘BACKGROUND Malignant hyperthermia(MH)is a hypermetabolic disorder of skeletal muscles triggered by exposure to volatile anesthetics and depolarizing muscular relaxants.It manifests with clinical presentations such as tachycardia,muscle rigidity,hyperpyrexia,and rhabdomyolysis in genetically predisposed individuals with ryanodine receptor or calcium voltage-gated channel subunit alpha1 S mutations.Local anesthetics,such as lidocaine,are generally considered safe;however,complications can arise,albeit rarely.Lidocaine administration has been reported to induce hypermetabolic reactions resembling MH in susceptible individuals.The exact mechanism by which lidocaine might trigger MH is not fully understood.Although some mechanisms are postulated,further research is needed for a better understanding of this.CASE SUMMARY We present the case of MH in a 43-year-old male patient with an unknown genetic predisposition following a lidocaine injection during a dental procedure.This case serves as a reminder that while the occurrence of lidocaine-induced MH is rare,lidocaine can still trigger this life-threatening condition.Therefore,caution should be exercised when administering lidocaine to individuals who may be susceptible to MH.It is important to note that prompt intervention played a crucial role in managing the patient’s symptoms.Upon recognizing the early signs of MH,aggressive measures were initiated,including vigorous intravenous normal saline administration and lorazepam.Due to the effectiveness of these interventions,the administration of dantrolene sodium,a specific antidote for MH,was deferred.CONCLUSION This case highlighted the significance of vigilant monitoring and swift action in mitigating the detrimental effects of lidocaine-induced MH.Caution should be exercised when administering lidocaine to individuals who may be predisposed to MH.It is very important to be aware and vigilant of the signs and symptoms of MH as early recognition and treatment intervention are important to prevent serious complications
基金Supported by Grant from Taipei Medical University(TMU101AE3-Y24 to JH Lin)MOST 103-2325-B-001-015 to ChenCCby grants from Ministry of Science and Technology,Taiwan,NO.NSC 102-2325-B-001-042,NSC102-2321-B-001-056 and NSC 102-2320-B-001-021-MY3 to Chen CC
文摘Lumbar radiculopathy, a group of diseases in which the dorsal root ganglia(DRG) or dorsal roots are adversely affected by herniated discs or spinal stenosis, are clinically characterized by spontaneous and evoked types of pain. The pain is underpinned by various distinct pathophysiological mechanisms in the peripheral and central nervous systems. However, the diagnosis of lumbar radiculopathy is still unsatisfactory, because the association of the pain with the neurobiological basis of radiculopathy is largely unknown. Several animal models used to explore the underlying neurobiological basis of lumbar radiculopathy could be classified as mechanical, chemical, or both based on the component of injury. Mechanical injury elevates the intraneural pressure, reduces blood flow, and eventually establishes ischemia in the dorsal root and the DRG. Ischemia may induce ischemic pain and cause nerve damage or death, and the subsequent nerve damage or death may induce neuropathic pain. Chemical injury predominately induces inflammation surrounding the dorsal roots or DRG and consequent inflammatory mediators cause inflammatory pain. Furthermore, DRG neurons sensitized by inflammatory mediators are hypersensitive to innocuous mechanical force(stretch or compression) and responsible for mechanical allodynia in radiculopathy. As well, central sensitization in the spinal cord may play an important role in pain generation in lumbar radiculopathy. Increasing knowledge of pain-generating mechanisms and their translation into clinical symptoms and signs might allow for dissecting the mechanisms that operate in each patient. With precise clinical phenotypic characterization of lumbar radiculopathy and its connection to a specific underlying mechanism, we should be able to design optimal treatments for individuals. This review discusses the present knowledge of lumbar radiculopathy and proposes a novel mechanism-based classification.
文摘Dexmedetomidine is a central alpha2-adrenergic receptor agonist with sedative and analgesic properties that has a proven safety profile. It has several beneficial effects such as decreasing sympathetic tone, leading to reduced opiate use and anxiolysis, making it an attractive option for sedation in the perioperative and intensive care unit setting. These effects also modify favorably the time spent on a ventilator, intensive care unit length of stay and development of delirium. Recent studies also suggest that dexmedetomidine possesses wide-ranging immunomodulating properties. It has been associated with reduced inflammatory cytokine release, modulation of inflammatory transcription factors, oxidative stress and inflammatory cells. These properties could be beneficial in the context of inflammatory conditions that require sedation, such as sepsis, ischemia-reperfusion injury and ventilator-associated lung injury, among many others. In this review, we propose specific clinical scenarios where these properties could turn out to be clinically relevant.
文摘Preeclampsia is a pregnancy specific syndrome of elusive etiology, developing in 2nd trimester and associated with high maternal and perinatal morbidity and mortality. The spectrum ranges from mild preeclampsia with no systemic involvement to multi-system involvement. The course is unpredictable and delivery is the only curative treatment. Elevated blood pressure(> 160/110 mm Hg) should be reduced gradually to a safe level(140/90) using antihypertensive drugs. Prophylaxis and treatment of convulsions using Mg SO4 is indicated for severe preeclampsia. Fluid therapy is controversial due to potential delicate balance between constricted plasma volume and risk of fluid overload and pulmonary oedema secondary to increased capillary permeability and reduced colloid osmotic pressure. Single shot spinal anaesthesia is the technique of choice for caesarean delivery unless contraindicated. General anaesthesia is indicated in patients with coagulopathy or eclampsia but is associated with risk of difficult airway and exaggerated sympathetic response during laryngoscopy. Epidural analgesia and anaesthesia is safe in absence of coagulopathy.
文摘Pigs are one of most common animal species to be used in biomedical models due to their many anatomical visceral similarities with humans, particularly with regards to transplantation. Despite this use, in many of the researches in which pigs are selected for transplantation, the anaesthesia used is an adaptation of human anaes-thesia and presents some limitations such as a reduced analgesia a limited control in perioperative period. In this review we show some of the most important conditions in the preanaesthetic management and of swine as well as we review of anaesthetic protocols for the most common types of swine model of transplantation.
文摘This review focuses on the mechanisms involved in hepatic ischemia-reperfusion(I/R) injury and effective therapeutic treatments associated with clinical anesthesia. Although hepatocytes are the main target cells in the whole process of I/R injury, Kupffer cells, as an initiator of harmful cascades, may play a vital role by releasing some proinflammatory mediators and reactive oxygen species in the early phase of I/R injury. The subsequent activation and recruitment of neutrophils are also involved in inflammatory response and immune activation. According to the above mechanisms, a number of strategies have been put forward in some experimental and clinical studies. Most of these therapeutic treatments originated from the generation of oxygen radicals and cytokines, the infiltration of neutrophils, the impairment of microcirculation and so on. Furthermore, increasing evidence has suggested that short periods of ischemic preconditioning have protective effects against liver I/R injury. Depending on these investigations, pharmacological preconditioning and clinical anesthesia-related effective methods have been proposed. A better understanding of the present progress on experimental statistics will bring about novel therapeutic treatments for the improvement of liver surgeries and transplantation.
文摘Phantom limb pain(PLP) is not uncommon after amputation. PLP is described as a painful sensation perceived in the missing limb. Despite of its complicated pathophysiology, high prevalence of PLP has been associated with poor health-related quality of life, low daily activity and short walking distances. A prompt and effective management of PLP is essential in caring for the amputee population. Current treatments including physical therapy, psychotherapy, medications, and interventions have been used with limited success. In this review,we provided an updated and evidence-based review of treatment options for PLP.
文摘Lung injury can arise during or after anesthesia and can lead to a complicated postoperative course with great implications for the patient. Unfortunately, treatment of acute lung injury is at the moment mainly supportive and rates of recovery have not really improved in the recent years. In many cases, lung injury can be anticipated and preventive measures seem possible. This represents a unique challenge to the anesthesiologist, as some new opportunities to reduce the frequency and/or severity of lung injury seem now available. These chances may arise from the potency of preconditioning the lungs before the main injury, with smaller injurious insults. Although preconditioning began to be applicated first on the myocardium, experimental studies have shown potentially beneficial results also for the lungs. This review summarizes the main methods of lung preconditioning that have been tried in experimental studies in the literature and the main mechanisms that are perhaps involved. Emphasis is given in the two main methods of preconditioning that seem readily applicable in the clinical praxis, that is ischemic preconditioning, as well as preconditioning with volatile anesthetics. The few, but interesting clinical studies are also summarized and the future research points in this evolving field of anesthesia are stressed.
文摘The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal(IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, costeffective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.
文摘Postoperative urinary retention(POUR) is one of the postoperative complications which is often underestimated and often gets missed and causes lot of discomfort to the patient. POUR is essentially the inability to void despite a full bladder in the postoperative period. The reported incidence varies for the wide range of 5%-70%. Multiple factors and etiology have been reported for occurrence of POUR and these depend on the type of anaesthesia, type and duration of surgery,underlying comorbidities, and drugs used in perioperative period. Untreated POUR can lead to significant morbidities such as prolongation of the hospital stay, urinary tract infection, detrusor muscle dysfunction, delirium, cardiac arrhythmias etc. This has led to an increasing focus on early detection of POUR.This review of literature aims at understanding the normal physiology of micturition, POUR and its predisposing factors, complications, diagnosis and management with special emphasis on the role of ultrasound in POUR.
基金Department of Anesthesiology at Rush University Medical Center for support
文摘AIM To determine if video laryngoscopy(VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation(FOI). METHODS Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009("pre-VL" group) and over the same 2-mo period after the introduction of VLs in 2012("postVL" group). Patient records with predicted difficult air-ways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.RESULTS To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually(P = 0.1768), it showed a trend toward significance when covariates were accounted for(P = 0.0910). Several factors predicting a higherlikelihood of awake FOI were found to be statistically significant: Morbid obesity(larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender(P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score(P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.CONCLUSION Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.
文摘Foreign body aspiration is a worldwide health problem which often results in life threatening complications. Tracheostomy tube fracture resulting in airway obstruction is a serious condition which has been reported in the medical literature. We report a rare case of a tracheostomy obturator fractured and lodged in tracheobronchial tree in a patient who presented with acute respiratory distress. Rigid or flexible bronchoscopy is frequently necessary for the diagnosis as well as the treatment. In adults, removal of the foreign body can be attempted during a diagnostic examination with a fiberoptic bronchoscope under lignocaine local infiltration with sedation, which may help to avoid any further invasive procedures. Flexible bronchoscopy should always be considered in foreign body aspiration. A periodic review of the techniques of tracheostomy care, including timely check-ups for signs of wear and tear, can possibly eliminate such avoidable late complications.
文摘In this review article, we describe a social-signaling perspective of human pain and pain empathizing behaviors which is based on the premise that pain percepts evolved to serve both intrapersonal as well as interpersonal, communicative functions. This perspective offers a generative framework for understanding the natural origin and proximate expression of felt pain and pain empathizing behaviors. The basic thesis is that humans evolved sensory-behavioral heuristics for perceiving and inhibiting exogenous and endogenous pain sensations as part of more general expressive styles characterized by the demonstration of vulnerability gestures(i.e., trustworthiness cues) versus empowerment gestures(i.e., capacity cues), and these styles ultimately facilitate broader selfprotection and social novelty-seeking life-history behavior strategies, respectively. We review the extant literature on how social contextual factors(e.g., audience characteristics) and how structural and functional components of individual's social network appear to influence the expression of pain behaviors in ways that support basic predictions from the social-signaling perspective. We also show how the perspective can be used to interpret conventional findings of sex differences in pain percepts and pain empathizing behaviors and for predicting how the situational context and individual's peer networks modulate these differences in vitro and in vitro. We conclude the article by describing how pain researchers may better understand how varying levels and divergent directions of changes in affect tend to co-occur with systematic changes in internal vs external pain sensitivities, and thus why, from an evolutionary perspective, pain may occur in the presence and absence of physical tissue damage.
文摘Dexmedetomidine is indicated as a sedative agent in intensive care units(ICUs). While several clinical trials and two meta-analyses have compared this agent with propofol or midazolam, the results were variable depending on the specific end-point(e.g., duration of mechanical ventilation, ICU mortality, maintaining a target depth of sedation, incidence of delirium episodes, length of hospital stay). Hence, the effectiveness of this new agent vs the comparators seems to be controversial. Trial sequential analysis(TSA) is a statistical technique that can estimate the optimal, cumulative number of patients that would be needed to generate a conclusive result. We therefore applied a TSA model to the most recent meta-analysis evaluating dexmedetomidine. A total of 10 randomized controlled trials were included in our analysis. According to our results, the comparison of dexmedetomidine vs propofol showed no proof of incremental effectiveness for the end-points of length of ICUs stay and incidence of delirium episodes. In contrast, futility(i.e., proof of no incremental effectiveness) was demonstrated for the end-point of mechanical ventilation. Hence, the results for the comparison of dexmedetomidine vs propofol were inconclusive for the first two end-points; on the other hand, conclusiveness was reached for the third end-point. We conclude that the place of dexmedetomidine in therapy of critically ill patients is very uncertain and further controlled trials are still needed.
文摘AIM: To compare the effectiveness and tolerability of paroxetine vs pregabalin for the management of multiple sclerosis(MS)-induced neuropathic pain(NPP).METHODS: A randomized, flexible-dose open-label 8-wk study involving 21 relapsing-remitting MS patients with MS-induced NPP was conducted to evaluate the effectiveness and tolerability of pregabalin versus paroxetine for pain management. The trial included a 3-wk dose titration phase followed by a 5-wk stable dose phase. Primary outcome measures included daily patient-reported pain intensity as measured using a 100 mm visual analogue scale(VAS pain) and daily impact of pain on daily activities(VAS impact). Hierarchical regression modeling was conducted on each outcome to determine if within person VAS trajectory for pain and impact differed across study groups, during 56 d follow-up. RESULTS: Attrition rates were significantly greater(P < 0.001) in the paroxetine versus pregabalin study group(70% vs 18.2%, respectively). Average study duration between study groups also significantly differed(P < 0.001). Paroxetine participants completed an average of 27.3 d of treatment vs 49.5 d in the pregabalin group, with the majority of patients withdrawing due to adverse events. Due to the high attrition rates in the paroxetine study arm, the investigators stopped the study prior to achieving complete recruitment. As such, no significant differences between pregabalin and paroxetine study arms were noted for the primary outcome measures(VAS pain, VAS impact). Comparative assessment of baseline patient characteristics also revealed no significant differences between the study arms. CONCLUSION: High attrition rates associated with paroxetine use suggest that it be used with caution for MS-induced NPP. Efficacy outcomes could not be assessed due to attrition.
文摘The zygapophysial joints(z-joints), together with the intervertebral disc, form a functional spine unit. The joints are typical synovial joints with an innervation from two medial branches of the dorsal rami. The joint capsule and the surrounding structures have an extensive nerve supply. The stretching of the capsule and loads being transmitted through the joint can causepain. The importance of the z-joints as a pain generator is often underestimated because the prevalence of z-joint pain(10%-80%) is difficult to specify. Z-joint pain is a somatic referred pain. Morning stiffness and pain when moving from a sitting to a standing position are typical. No historic or physical examination variables exist to identify z-joint pain. Also, radiologic findings do not have a diagnostic value for pain from z-joints. The method with the best acceptance for diagnosing z-joint pain is controlled medial branch blocks(MBBs). They are the most validated of all spinal interventions, although false-positive and false-negative results exist and the degree of pain relief after MBBs remains contentious. The prevalence of z-joint pain increases with age, and it often comes along with other pain sources. Degenerative changes are commonly found. Z-joints are often affected by osteoarthritis and inflammatory processes. Often additional factors including synovial cysts, spondylolisthesis, spinal canal stenosis, and injuries are present. The only truly validated treatment is medial branch neurotomy. The available technique vindicates the use of radiofrequency neurotomy provided that the correct technique is used and patients are selected rigorously using controlled blocks.
文摘BACKGROUND Heart failure is generally regarded as a progressive and irreversible medical condition.The EVAHEART is an implantable left ventricular assist system.CASE SUMMARY We report the anesthesia management of a 56-year-old male patient with dilated cardiomyopathy undergoing an EVAHEART implantation.Transesophageal echocardiography is crucial to ensure the correct positioning of the device and the proper aortic valve outflow.Because the continuous blood flow device functions best under low systemic and pulmonary vascular resistance,milrinone is the preferred drug.Our patient was accompanied by pulmonary hypertension,so during the operation,nitric oxide was used to reduce pulmonary artery pressure.CONCLUSION The cardiac output achieved by the patient with the assistance of EVAHEART can reach 4 L/min,which of course depends on the front load,rear load,and pump speed.
基金Supported by The Austrian Federal Ministries of Science,Research and Economy and of Health and by Eurasia-Pacific Uninet(project"Evidence-based high-tech acupuncture and integrative laser medicine for prevention and early intervention of chronic diseases")
文摘Using acupuncture instead of anesthetics to induce analgesia was performed in China many years ago in surgical anesthetization. Although many medical units in China's cities and rural areas are applying these techniques in operations, it should be pointed out that acupuncture anesthesia is still in the process of development and is of next to no practical and even less scientific value in the western world. However, acupuncture-assisted anesthesia can be useful also in countries other than China.
