ARTICLE | doi:10.20944/preprints202309.1102.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Central Nervous System Disease, Complementary Therapies, Virtual Reality, Pain, Anxiety
Online: 18 September 2023 (07:03:53 CEST)
Background and Objectives: Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, inno-vative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the man-agement of procedural pain. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intra-muscular injections of botulinum toxin. Materials and Methods: Twenty-one adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patient reported the pain experienced during previous injections without VR before injection and the pain expe-rienced in the current procedure with VR after the end of the procedure. Level of satis-faction of VR experience, if they agreed to reuse VR for the subsequent toxin botulinum injection, and if they would recommend VR to other patients were assessed. Results: The use of virtual reality showed a decrease of 1.8 pain-related points compared to without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied by their VR experience (7.9 out of 10) and would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%). Conclusion: VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patient. VR should be considered as a valuable alternative to pharmacological approach to manage procedural pain during Botulinum toxin injection in adults.
ARTICLE | doi:10.20944/preprints202309.0346.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: abdominal aortic aneurysm; endovascular procedure; prognosis; complications, postoperative; acute kidney injury; biomarkers; myocardial infarction; arrhythmia; cerebrovascular accident
Online: 6 September 2023 (08:52:24 CEST)
The 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) was evaluated and the possible predictors were identified. Demographics, medical history, laboratory values, length of hospitalization (LOH), intensive care unit (ICU) admission and 30-day complications, classified as major [major adverse cardiovascular events (MACE), acute kidney injury (AKI) and death of any cause] and minor [post-implantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure] were documented, respectively. We included 322 patients (median LOH 4 days). One-hundred and twenty one (37.5%) complications, mostly minor (n=103, 31.9%), were recorded. Eleven patients (3.4%) evolved MACE, 5 (1.6%) AKI and 2 patients (0.6%) died in ICU. Seventy-seven patients (23.9%) suffered from PIS, eleven from POD, 11 from UTI and 4 from technical graft failure. Multivariate logistic regression analysis revealed that aneurysm diameter (p=0.01) and past smoking (p=0.003) were predictors for postoperative complications. PAD was an independent predictor of MACE (p=0.003), preoperative neutrophil to lymphocyte ratio (NLR) value of AKI (p=0.003) and past smoking of PIS (p=0.008), respectively. Our study showed that 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were classified as minor and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.
ARTICLE | doi:10.20944/preprints202309.0119.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: opioids; adverse effect database; FAERS, reporting odds ratio; cluster analysis
Online: 4 September 2023 (04:07:36 CEST)
Adverse events associated with opioid use in palliative care have been extensively studied. However, predicting the occurrence of adverse events based on the specific opioid used remains unclear. This study aimed to comprehensively analyze the adverse events caused by µ receptor stimulation of opioids approved in Japan and investigate the tendencies of adverse event occur-rence among different opioids.We utilized the FDA Adverse Event Reporting System (FAERS) database to extract reported adverse events of opioids approved in Japan. Cluster analysis was performed on reporting odds ratios (RORs) of adverse event names among opioids to visualize relationships between opioids and adverse events, facilitating a comparative study of their clas-sifications.We calculated the RORs of adverse events for the target opioids. Based on these RORs, we performed a cluster analysis, which resulted in the classification of 11 target opioids into five distinct groups. we were able to comprehensively compare and examine the relationships between opioids and adverse events. This analysis helps in understanding and managing the risks and benefits of each drug in palliative care settings. By analyzing relationships between opioids and adverse events, clinicians can make informed decisions about opioid selection, dosage, and monitoring to maximize patient safety and comfort.
ARTICLE | doi:10.20944/preprints202309.0011.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: immunoassay; urine drug test; opioid; nonmedical; cancer pain; safety-net hospital; palliative medicine; education
Online: 1 September 2023 (04:02:26 CEST)
BACKGROUND: Few studies have examined the use of immunoassay urine drug testing of cancer patients in palliative care clinics. OBJECTIVES: We examined the frequency of immunoassay urine drug test (UDT) abnormalities and the factors associated with aberrancy at a safety-net hospital palliative medicine clinic. METHODS: A retrospective review of the electronic medical records of consecutive eligible patients seen at the outpatient palliative medicine clinic in a resource-limited safety net hospital system was conducted between September 1, 2015 and December 31, 2020. We collected longitudinal data on patient demographics, UDT findings, and potential predictors of aberrant results. RESULTS: Of the 913 patients in the study, 500 (55%) underwent UDT testing, with 455 (50%) having the testing within the first three visits. Among those tested within the first three visits, 125 (27%) had aberrant UDT results; 44 (35%) of these 125 patients were positive for cocaine. In a multivariable regression model analysis of predictors for aberrant UDT within the first 3 visits, non-Hispanic White race (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.03-4.38; p=0.04), history of illicit drug use (OR=3.57; CI: 1.78-7.13; p< 0.001), and history of marijuana use (OR=7.05; CI: 3.85-12.91; p< 0.001) were independent predictors of an aberrant UDT finding. CONCLUSION: Despite limitations of immunoassay UDT, it was able to detect aberrant drug taking behaviors in a significant number of patients seen at a safety net hospital palliative care clinic, including cocaine use. These findings support universal UDT monitoring and utility of immunoassay-based UDT in resource limited settings.
ARTICLE | doi:10.20944/preprints202308.1926.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Blood gas analysis; Point-of-care diagnostic; Qualitative research; Situation awareness; User-centered design; Visualization; Visual Blood
Online: 29 August 2023 (09:14:04 CEST)
Blood gas analysis plays a central role in modern medicine. Advances in technology have expanded the range of available parameters and increased the complexity of their interpretation. By applying user-centered design principles, it is possible to reduce the cognitive load associated with interpreting blood gas analysis. In this international, multicenter study, we explored anesthesiologists' perspectives on Visual Blood, a novel visualization technique for presenting blood gas analysis results. We conducted interviews with participants following two computer-based simulation studies: the first utilizing Virtual Reality (VR) (50 participants) and the second without VR (70 participants). Employing the template approach, we identified key themes in the interview responses and formulated six statements, which were rated using Likert scales: from 1 (strongly disagree) to 5 (strongly agree) in an online questionnaire. The most frequently mentioned theme was the positive usability features of Visual Blood. The online survey revealed that participants found Visual Blood to be an intuitive method for interpreting blood gas analysis (median 4, IQR 4-4, p<0.001). Participants noted that minimal training was required to effectively learn how to interpret Visual Blood (median 4, IQR 4-4, p<0.001). However, adjustments are necessary to reduce visual overload (median 4, IQR 2-4, p<0.001). Overall, Visual Blood received a favorable response. The strengths and weaknesses derived from these data will help optimize future versions of Visual Blood to improve the presentation of blood gas analysis results.
ARTICLE | doi:10.20944/preprints202308.1763.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Doppler ultrasound; Corrected time flow; Fluid responsiveness; Robotics
Online: 28 August 2023 (10:32:40 CEST)
This prospective study aimed to evaluate the ability of point-of-care Doppler ultrasound measurements of carotid-corrected flow time and changes in corrected carotid flow time (FTc) induced by volume expansion to predict fluid responsiveness in patients undergoing robot-assisted gynecological surgery in a modified head-down lithotomy position. FTc was measured using Doppler images of the common carotid artery before and after volume expansion. The stroke volume index at each time point was recorded using the MostCare instrument. Fluid responsiveness was defined as a stroke volume index ≥10% increase after volume expansion. Half (50%) of the 52 patients responded positively. The areas under the receiver operating characteristic curves measured to predict fluid responsiveness for the corrected carotid flow time and changes in the FTc were 0.82 [95% confidence interval:0.705–0.937; P < 0.0001] and 0.67 (95% confidence interval:0.520–0.815; P < 0.05), respectively. The optimal cut-off value for the FTc and the change in FTc were 356.5 ms and 19.5 ms, respectively. FTc is a more reliable predictor of fluid responsiveness than FTc induced by volume expansion in gynecological patients undergoing robot-assisted laparoscopic surgery in the modified head-down lithotomy position.
REVIEW | doi:10.20944/preprints202308.1816.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: intranasal administration; emergency department; migraine; primary headache disorder; analgesics; acute pain management; pain; ketamine; fentanyl; paracetamol; ketorolac; nsaid
Online: 28 August 2023 (08:22:31 CEST)
In the Emergency Department (ED), pain is one of the symptoms that is most frequently reported, making it one of the most significant issues for the emergency physician, but is frequently under treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondary, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a systematic review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library and Controlled Trials Register finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. IN is simple to administer, non-invasive, rapid onset and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management. Analgesia needs to be tailored to each patient's features and type of pain: IN Fentanyl and Ketamine look promising and may be administered easily and safely while providing effective pain relief.
ARTICLE | doi:10.20944/preprints202308.0130.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Breast Cancer; Acute Postoperative Pain; Postoperative analgesia; Patient-Controlled Analgesia; Levobupivacaine; Diclofenac; Hand Grip Strength; Quality of life; Treatment Outcome; Long term survival.
Online: 2 August 2023 (04:37:34 CEST)
Breast cancer is the most common malignant disease in women. Preclinical studies have confirmed that the local anesthetic levobupivacaine has a cytotoxic effect on breast cancer cells. We examined whether postoperative wound infiltration with levobupivacaine influences survival in 120 patients who were operated on for breast cancer and underwent quadrantectomy or mastectomy with axillary lymph node dissection. Groups with continuous levobupivacaine wound infiltration, bolus wound infiltration, and diclofenac analgesia were compared. Long-term outcomes examined were quality of life, shoulder disability, and hand grip strength (HGS) after one year, and survival after 5 and 10 years. Groups that had infiltration analgesia had better shoulder function compared to diclofenac after one year. Levobupivacaine PCA group had the best preserved HGS after 1 year (P=0.022). The most significant predictor of the 5-year outcome was HGS (P=0.03). Although the best survival after 5 and 10 years was registered in the bolus levobupivacaine group, statistical significance was not reached (P=0.36). The extent of the disease at the time of surgery is the most important predictor of long-term survival. A larger prospective clinical study could better confirm the effect of levobupivacaine wound infiltration on outcomes after breast cancer surgery observed in this pilot study. Trial number NCT05829707
CASE REPORT | doi:10.20944/preprints202307.1350.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: intubation granuloma; airway management; general anesthesia; pregnancy
Online: 20 July 2023 (05:12:06 CEST)
Anesthetic management for pregnant suffering from airway pathology poses unique challenges. The presence of bilateral vocal cord granuloma adds further complexity to the management, as it can potentially cause airway compromise and respiratory distress. This case presents a pregnant patient with bilateral vocal cord granuloma who underwent anesthesia using high-flow nasal cannula (HFNC) oxygenation and oxygen reserve index (ORi) monitoring. A 33-year-old pregnant woman, who had undergone intubation six month ago, experienced hoarseness and was ultimately diagnosed with bilateral granuloma. Due to the significant airway obstruction, neither intubation nor ventilation was feasible, thereby requiring a surgical intervention. Before the surgical removal, the patient’s oxygenation was ensured using HFNC oxygenation. After confirming sufficient oxygenation of the patient with ORi of 0.38, the operation commenced and as it lasted approximately 3 minutes, the patient was able to tolerate the brief period without additional oxygen supply. Post-surgical excision, mask bagging and HFNC oxygenation was resumed, driving ORi to 0.39, then the operation was resumed. Throughout the procedure, SpO2 remained above 98. The combination of HFNC and ORi ensured adequate oxygenation and allowed for early detection of hypoxemia during the procedure. This approach may be a good option for managing granuloma.
ARTICLE | doi:10.20944/preprints202307.1011.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Intraoperative Complications; Gaucher Disease; General Anesthesia; Regional Anesthesia; Total Hip Arthroplasty,
Online: 14 July 2023 (11:25:28 CEST)
Gaucher Disease's (GD) pathophysiology generates anesthetic concerns in Total Hip joint Arthroplasty (THA), and due to its rareness, data on perioperative risks is scarce. This 22-year study at a large reference center addresses anesthetic management and perioperative outcomes in GD. This retrospective-cohort study assessed anesthetic success and safety in 30 THA patients, comparing them with a control-matched group. Data on clinical characteristics, perioperative events, and outcomes were collected. The primary outcome was difficult anesthesia-initiation incidence. Secondary outcomes were difficult intraoperative course and hemodynamic management, and the development of postoperative-complications. The age, sex, weight, body mass index, primary-to-revision hip arthroplasty ratio were similar in both groups. The mean age was 48±13 years. Ten arthroplasties were revision while twenty were primary. There was no significant difference at all-type anesthesia first initiation attempt success. No particular preference by staff anesthetists for general anesthesia or neuraxial procedures was observed. The GD group showed significantly higher mean intraoperative packed red blood cell units administered (0.73 vs 0.18);(p= 0.038)), higher intraoperative and postoperative platelet transfusion incidence (5/30 [16.7%] vs. 0/56 [0.00%];p=0.004) and (3/30 [10%] vs 0/56 [0%];p=0.040) and longer mean recovery-room length-of-stay (426±412 vs 175±140;p=0.004). Postoperative complications were not significantly different.
ARTICLE | doi:10.20944/preprints202306.1683.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: TBI; Cerebrolysin; Amantadine; neuromonitoring; NIRS; ONDS; ICP; SjO2
Online: 23 June 2023 (12:38:37 CEST)
TBI is one of the most common causes of death and long term damage to health worldwide. The approved guidelines for patients with TBI include standards of treatment. However, there is lack of guidelines for monitoring or neuroprotective treatment. Cerebrolysin is a drug with a proven beneficial effect on treatment outcome in patients with TBI. There are also reports of the beneficial effect of Amantadine. Studies on the use of additional neuromonitoring are also published with increasing frequency. We decided to investigate how the result of treatment changed with the administration of Cerebrolysin and Amantadine and with additional neuromonitoring. In an observational study, we collected data on 56 patients. After the statistical analysis, it could be shown, that Cerebrolysin monotherapy increases Glasgow Outcome Scale (GOS) among our patients and it was found to interact significantly with Amantadine and neuromonitoring approach in the group of severe TBI. In conclusion, it is worth considering a multimodal approach to the treatment and monitoring of patients with TBI. However, more randomized studies are needed to confirm the method of monitoring or conducting neuroprotective therapy in patients with TBI.
ARTICLE | doi:10.20944/preprints202306.1516.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Pulmonary aspiration; gastric ultrasound; antrum; gastric volume; elective surgery
Online: 21 June 2023 (09:54:17 CEST)
Pulmonary aspiration is a serious anaesthetic complication with morbidity and up to 9% of all anaesthesia-related mortality. Aspiration risk is especially focused on fastening time. We aimed to evaluate the prevalence of 'risky stomach' defined by ultrasound imagine of solid contents and/or calculated gastric fluid volume >1.25 mL/kg in elective surgery also comparing this definition with the 0-2 qualitative rating scale used for "empty/risky stomach". This prospective study has 97 patients aged 2-18. Ultrasonographic evaluations of the gastric antrum content is scaled with qualitative assessment in supine and right lateral decubitus (RLD) position. Gastric volume was calculated. In our study, stomach content and volume were evaluated by ultrasound in 97% of children and 5.2% had Grade 2 antrum. In RLD position, antral CSA was 2.36 cm², and the median gastric volume was 0.46 mL/kg. In patients with grade 0 antrum has moderate and positive correlation between antral CSA and BMI, and strong and positive correlation between antral CSA and age like grade 1 antrum. We showed that 0.1%-4.7% of elective children had gastric fluid volumes of >1.25 mL/kg as "risky stomach". Ultrasound for gastric contents could be used routine practice to determine pulmonary aspiration risk in emergency and elective procedures.
BRIEF REPORT | doi:10.20944/preprints202306.1418.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Styletubation; video-assisted intubating stylet; obesity; super-super obesity; bariatric surgery; laparoscopic sleeve gastrectomy; tracheal intubation; laryngoscopy; videolaryngoscope; anesthesia; difficult airway
Online: 21 June 2023 (02:17:23 CEST)
Direct laryngoscope and videolaryngoscope are the dominant endotracheal intubation tools. Styletubation technique (using a video-assisted intubating stylet) has shown its advantages regarding in short intubation time, high success rate, less stimulation, and operator’s satisfaction. The learning curve can be steep but easy to overcome if the technical pitfalls could be avoided. Conditions make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, and obesity, etc. In this clinical report, we present the effectiveness and efficiency of routine use of the styletubation for tracheal intubation in a super-super obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.
ARTICLE | doi:10.20944/preprints202306.1454.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: vasopressin; vasopressin receptor agonist; hemorrhagic shock; resuscitation; hemodynamics; outcome
Online: 20 June 2023 (14:57:33 CEST)
Background: The clinical impact of vasopressin in hemorrhagic shock remains largely unknown. Objective: This systematic review and meta-analysis was designed to investigate the effects of vasopressin receptor agonists during the resuscitation of hemorrhagic shock. Methods: A systematic search of PubMed (MEDLINE), Scopus, and PubMed Central was conducted for relevant articles. Preclinical (animal) and clinical studies were included. The primary objective was to investigate the correlation of vasopressin receptor agonist use with mortality and various hemodynamic parameters. Results: Data extraction was possible in 13 animal studies and two clinical studies. Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents [RR (95%CI): 1.17 (0.67, 2.08); p=0.562; I2 = 50%]. The available data were insufficient to conduct a meta-analysis assessing the effect of vasopressin receptor agonists on hemodynamics. Drawing safe conclusions from animal studies was challenging, due to significant heterogeneity in terms of species and dosage of vasopressin receptor agonists across studies. Conclusions: Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents after hemorrhagic shock.
REVIEW | doi:10.20944/preprints202306.1061.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: cancer pain; cancer survivors; neuropathic pain; opioids; WHO analgesics ladder
Online: 14 June 2023 (15:05:53 CEST)
Pain is frequently reported during cancer disease, and still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Thereby, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discuss the different options currently available to manage pain in (former) cancer patients in the light of progress made in the last decade. Major progress in the field are recent development of a chronic cancer pain taxonomy now included in International Classification of Diseases (ICD-11) and update of WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, opioids being considered as mainstay. The opioids crisis has prompted the reassessment of opioids use, both in cancer patients and cancer survivors. The review focuses on the current utilization of opioids, on the neuropathic pain component often neglected and on techniques and non-pharmacological strategies available which help to personalize patient’s treatment. Cancer pain management is now closer to the management of chronic non-cancer pain i.e. “an integrative pain care” aiming to improve patient’s quality of life.
ARTICLE | doi:10.20944/preprints202306.0913.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: COVID-19,methaemoglobin level; transfusion; mortality
Online: 13 June 2023 (09:32:04 CEST)
Background : Our objectives were to investigate the incidence of elevated methemoglobin level among COVID-19 patients at intensive care unit. The correlation of methaemoglobinemia with mortality and some haematological parameters was also tested. Methods: The diagosis of coronavirus -19 infection was confirmed by RT-PCR. The quantitative method for determination of methemoglobin was it’s cyanide derivative by spectrophotometry. The reference range was less than 2 percent. Results: There were altogether 46 patients (11 male, 35 female) included. Their median age value was 70 y. ( 29 – 89). The methemoglobin median value was 4,3%. 15 of 46 patients died. The methemoglobin median value of departed patients was 8 % , and 2,5% was among survivors. ( P= 0,001) 19 patients were blood transfused. Their methemoglobin median was 11 % , otherwise the non transfused patients presented 2,7 % methemoglobin median. ( p= 0,001). We performed two binary logistic regression calculation, in order to judge the elevated methemoglobin level as an independent risk factor for the mortality. The predictor of methaemoglobin was 0,062 the constant -1,266 the odds ratio 1,06. The other binary logistic regression tested the fact of transfusion for the mortality. Predictor of transfusion 1,1474, constant -1,2527 odds ratio 3,15 There was no significant correlation between methemoglobin and CRP level. Discussion: The methemoglobin is not able to transport oxygen. It’s association with mortality is discussed by some papers.There are several hypothesis in the literature to explain it’s occurrence in COVID-19. The role of coronavirus proteins as oxydative agents was mentioned. The importance of enzyme defect is emphasized. The impact of reactive oxygen free radicals in inflammation is also probable. Some papers mentioned applying local anesthetics and azythromycin as a risk. The role of transfusion is obscure, because the methemoglobin can be elevated in blood conserves during storage. Conclusion: Testing the methemoglobin seems to be important, but the pathomechanism needs further research.. The traceability and standardization of different measurement methods at intensive care units is the key for defining it’s pathogenetic role.
REVIEW | doi:10.20944/preprints202306.0168.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: hydroxyethyl starch; acute kidney injury; hemodynamic monitoring; sepsis; cardiac; postoperative
Online: 2 June 2023 (09:28:13 CEST)
Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship; the AKI-inducing property of 6% HES 130/0.4 or 0.42 could not be accounted as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusion: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Further conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.
ARTICLE | doi:10.20944/preprints202306.0063.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: chronic pain; non-pharmaceutical pain management; interventions
Online: 1 June 2023 (08:13:11 CEST)
Background: Chronic, non-cancer pain represents a serious public health and economic issue affecting approximately 20% of the global population. Chronic pain can affect many aspects of patient’s lives, including mental health, employment, and relationships. Current medical management is largely focussed on investigating and managing acute pain. Patients and clinicians are now increasingly aware of the potential benefits of combined treatments or complex interventions in alleviating chronic pain. These approaches include both physical interventions, such as exercise or yoga, as well as psychological support including cognitive behavioural therapy (CBT) and talking therapies. Methods: This study used network meta-analyses to explore the prevalence of complex interventions in pain management, and the effects of these interventions on quality of life, using outcome measures including intensity of chronic pain, assessment of functional disability and participant’s psychological state. Results: Psychological interventions were associated with improvements in pain intensity and depression. Exercise and manipulation technique-based treatments provided a statistically significant reduction in pain intensity. This effect was enhanced when exercise and CBT were combined. Mensendieck somatocognitive therapy (MSCT) plus standard gynaecological treatment (STGT) treatments appeared to have a better effect on chronic pain than multimodal exercise plus CBT treatment. Combined MSCT and STGT treatment, and multimodal exercise plus CBT treatments, reduced pain intensity, whilst MSCT+STGT treatments had a slightly better effect than exercise plus CBT treatment.Conclusions: Complex interventions have become more popular with patients as the risks associated with other interventions including surgery and pharmacological management have become better understood. These interventions can have a significant positive effect both on the physical and psychological health of patients. The analysis presented in this study suggests that further work is warranted in this area and that additional studies are required, both in more geographically diverse locations, and with larger cohorts.
ARTICLE | doi:10.20944/preprints202305.1584.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Body temperature; Elderly patient; Orthopedic surgery; Zero-Heat-Flux thermometer
Online: 23 May 2023 (05:32:17 CEST)
Thermoregulation is important for maintaining homeostasis of our body. It can be easily broken under anesthesia. An appropriate method to measure the core body temperature is needed, especially for elderly patients because the efficiency of thermoregulation gradually decreases with age. The aim of this study was to examine the accuracy and feasibility of using of SpotOn® sensor in lower extremity orthopedic surgery in elderly patients aged over 80 years by comparing a SpotOn® sensor with two other reliable minimal-invasive methods: a tympanic membrane thermometer and a bladder thermometer. This study enrolled 45 patients aged over 80 years who were scheduled to undergo a lower extremity surgery. Body temperature was measured using a SpotOn® sensor, tympanic membrane thermometer and bladder thermometer. Agreements between the SpotOn® sensor and the other two methods were assessed using Bland and Altman plots for repeated measures adjusted for unequal numbers of measurements per patient. Compared with TempBladder, bias and limits of agreement for TempZHF were 0.07℃ ± 0.58℃. Compared with TempTympanic, bias and limits of agreement for TempZHF were -0.28℃ ± 0.61℃. 3M SpotOn® sensor using ZHF method for patients aged over 80 years undergoing lower extremity surgery shows feasible measurement value and sensitivity.
ARTICLE | doi:10.20944/preprints202305.1152.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Hypothermia; abdominal surgery; Risk factors
Online: 16 May 2023 (10:33:27 CEST)
Objective: To describe the proportion of patients undergoing major abdominal surgery who develop postoperative hypothermia, and the variables associated with its occurrence. Material and Methods: We conducted a prospective cohort study in a tertiary care referral hospital in Mexico City to describe the incidence of perioperative hypothermia and factors associated with postoperative hypothermia. A repeated measures ANOVA model was used to compare preoperative, intraoperative, and postoperative temperatures. Potential variables associated with hypothermia were evaluated with a logistic regression analysis. Results: A total of 110 patients were included in the analysis. Of them, 61% (n=67) were women. The mean age was 56.7 years (SD: 16.3, range: 75). The most frequently involved organ on which surgery was performed was kidney or urinary tract (21.8%), followed by large bowel (14.5%) and exploratory laparotomy (14.5%). The incidence of postoperative hypothermia in patients undergoing major abdominal surgery was 57.3%, while preoperative and intraoperative hypothermia occurred in 55.5% and 79.1%, respectively. Age over 60 years was the only variable associated with postoperative hypothermia after multivariable adjustment for sex, age, and time surgery (OR=18.4, 95% CI:3.79-89.6, p<0.0001). Conclusion: Increasing age was the only variable associated with postoperative hypothermia in patients undergoing major abdominal surgery.
REVIEW | doi:10.20944/preprints202305.0562.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Facet joint injection; Chronic low back pain; Normal saline; Meta-analysis; Patient Reported Clinical Outcomes
Online: 9 May 2023 (04:22:14 CEST)
Objective: This systematic review and meta-analysis compared the patient-reported outcomes of intra-articular facet joint injections of normal saline and selected active substances to identify a more effective agent for treating subacute and chronic low back pain (LBP). Methods: The PubMed, Embase, Scopus, Web of Science, and CENTRAL databases were searched for randomized controlled trials and observational studies published in English. A research quality assessment was performed using ROB2 and ROBINS-I. A meta-analysis was conducted using a random-effects model, and the mean differences (MD) with 95% confidence intervals (CI) in efficacy outcomes, including pain, numbness, disability, and quality of life, were assessed. Results: Of the 2,467 potential studies, three were included (247 patients). The active substances and normal saline had similar therapeutic effects on pain within 1 h, after 1-1.5 months, and after 3-6 months, with MD and 95% CI of 2.43 and -11.61 to 16.50, -0.63 and -7.97 to 6.72, and 1.90 and -16.03 to 19.83, respectively, as well as the quality of life after 1 and 6 months. Conclusion: The short- and long-term clinical effects of intra-articular facet joint injections of normal saline are comparable to those of other active substances in patients with LBP.
REVIEW | doi:10.20944/preprints202305.0264.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Artificial Intelligence; Machine Learning; Anesthesia; Ethics
Online: 4 May 2023 (11:11:19 CEST)
The field of anesthesia has always been at the forefront of innovation and technology, and the integration of Artificial Intelligence (AI) represents the next frontier in anesthesia care. The use of AI and its subtypes such as machine learning has the potential to improve efficiency, reduce costs, and improve patient outcomes. AI can assist with decision-making, but its primary advantage lies in empowering anesthesiologists to adopt a proactive approach to address clinical issues. However, further research and validation are needed to fully understand the benefits and limitations of these applications in clinical practice. Moreover, the ethical implications of AI in anesthesia must also be considered to ensure that patient safety and privacy are not compromised. This paper aims to provide a comprehensive overview of AI in anesthesia, including its current and potential applications, and the ethical considerations that must be considered to ensure the safe and effective use of the technology.
COMMUNICATION | doi:10.20944/preprints202304.0789.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: sacroiliac; fusion; intra-articular; minimally invasive
Online: 23 April 2023 (08:03:17 CEST)
Abstract: (1) Background: Minimally-invasive sacroiliac joint (SIJ) fusion is the preferred surgical intervention to treat chronically severe pain associated with SIJ degeneration and dysfunction. (2) Methods: This paper details the ten-step surgical procedure associated with the postero-inferior approach using the PsiF™DNA Sacroiliac Joint Fusion System. (3) Results: The posterior surgical approach with an inferior operative trajectory (postero-inferior) utilizes easily identifiable landmarks to provide the safest, most direct access to the articular joint space for transfixing device placement. Implanting the device through the subchondral bone, provides maximum fixation and stabilization of the joint by utilizing an optimal amount of cortical bone-implant interface. Approaching the joint from the inferior trajectory also places the implant perpendicular to the S1 endplate at a “pivot point” near the sacral axis of rotation, which addresses the most significant motion of the joint. (4) Conclusions: Further observational data from real-world clinical use are encouraged to further validate this procedure as the surgical preference for minimally-invasive SIJ fusion.
ARTICLE | doi:10.20944/preprints202303.0123.v2
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: chronic pain; patient education; vulnerable populations; low income; quality of life
Online: 14 March 2023 (01:42:07 CET)
Chronic pain is a source of major alterations in quality of life. It represents significant costs for health systems, and reduces the competitiveness of the working population. Vulnerability can drive the incidence of chronic pain, through its influence on modifiable risk factors, and reduced utilization of health care systems. But vulnerability can also be the consequence of a chronic pain: illness can push people into precariousness. We analysed the factors associated with pain intensity among vulnerable persons with a chronic condition, in five European countries (N=1,364). Pain was, among the whole set of variables, the main predictor of sleep problems, fatigue, depression, self-perceived health, physical and mental quality of life. This is in line with other studies showing the major impact of pain on an individual’s health and life. Multivariable analyses, adjusting for the whole set of variables, showed that women had more intense pain, as well as participants with a lower education level. These results confirm the social component in the complex etiology of pain and clearly plaid in favor of integrated care, taking into account individual characteristics and environment.
ARTICLE | doi:10.20944/preprints202302.0433.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: ECLS; ECMO; animal model; rodent; rat; mouse; hamster; CPB; in-vivo; oxygenator
Online: 27 February 2023 (02:41:38 CET)
The survival rate of extracorporeal life support (ECLS) remains overall at 60 %. Research and development is slow, partly due to the lack of sophisticated experimental models. This publication introduces a dedicated rodent oxygenator (“RatOx”) and shows preliminary in vitro classification tests. The RatOx has an adaptable fiber module size for various rodent models. Gas transfer performance over the fiber module for different blood flows and fiber module sizes were tested according to DIN EN ISO 7199.At the maximum possible amount of effective fiber surface and a blood flow of 100 ml/min, the oxygenator performance has been tested to a maximum of 6.27 ml O2/min and 8.2 ml CO2/min, respectively. The priming volume for this the largest fiber module is 5.4 ml, while the smallest possible configuration with a single fiber mat layer has 1.1 ml of priming volume. The novel RatOx ECLS system has been evaluated in-vitro to comply to a high degree with all predefined functionality criteria for rodent sized animal models. We intend for the RatOx to become a standard testing platform for scientific studies on ECLS therapy and technology.
ARTICLE | doi:10.20944/preprints202302.0344.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: oxygen transport; cardioprotection; hypoxic-hyperoxic preconditioning; ischemia-reperfusion injury; cardiopulmonary bypass; endothelial damage markers
Online: 20 February 2023 (15:14:26 CET)
Background: The hypothesis is that a hypoxic-hyperoxic preconditioning (HHP) is associated with a protective effect on myocardial function by reducing endothelial damage and a beneficial effect on postoperative outcome in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: Patients (n=120) were randomly assigned to an HHP and a control group. A safe inhaled oxygen fraction for the hypoxic preconditioning phase (10-14% oxygen for 10 minutes) was determined by measuring the anaerobic threshold. At hyperoxic phase, 75-80% oxygen fraction was used during 30 minutes. Results: The cumulative frequency of postoperative complications was 14 (23.3%) in the HHP vs 23 (41.1%), p=0.041. The nitrate decreased after surgery by up to 20% in the HHP group and up to 38% in the control group. Endothelin-1 and nitric oxide metabolites were stable in HHP but remained low more than 24 h in control group. The endothelial damage markers appeared to be predictors of postoperative complications. Conclusion: The HHP with individual parameters based on the anaerobic threshold is a safe procedure, it can reduce the frequency of postoperative complications. The endothelial damage markers appeared to be predictors of postoperative complications.
ARTICLE | doi:10.20944/preprints202302.0338.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Piezoelectric; Piezocapacitive; Pulse transit time; Non-invasive hemodynamics; Intraoperative blood pressure; Anesthesiology
Online: 20 February 2023 (09:43:32 CET)
Abstract: Background: Non-invasive acquistion of beat-to-beat pulse transit time (PTT) via piezoelectric/piezocapacitive sensors (PES/PCS) may expand perioperative hemodynamic monitoring. This study evaluated the ability for PTT via PES/PCS to correlate with systolic, diastolic, and mean invasive blood pressure (SBPIBP, DBPIBP, and MAPIBP) and to detect SBPIBP fluctuations. Methods: PES/PCS and IBP measurements were performed in 20 patients undergoing abdominal, urological, and cardiac surgery. A Pearson’s correlation analysis (r) between 1/PTT and IBP was performed. The predictive ability of 1/PTT with changes in SBPIBP was determined by area under the curve (reported as AUC, sensitivity, specificity). Results: Significant correlations between 1/PTT and SBPIBP were found for PES (r=0.64) and PCS (r=0.55) (p<0.01), as well as MAPIBP/DBPIBP for PES (r=0.6/0.55) and PCS (r=0.5/0.45) (p<0.05). A 7% decrease in 1/PTTPES predicted a 30% SBPIBP decrease(0.82, 0.76, 0.76), while a 5.6% increase predicted a 30% SBPIBP increase (0.75, 0.7, 0.68). A 6.6% decrease in 1/PTTPCS detected a 30% SBPIBP decrease (0.81, 0.72, 0.8), while a 4.8% 1/PTTPCS increase detected a 30% SBPIBP increase (0.73, 0.64, 0.68). Conclusions: Non-invasive beat-to-beat PTT via PES/PCS demonstrated significant correlations with IBP and detected significant changes in SBPIBP. Thus PES/PCS as a novel sensor technology may augment intraoperative hemodynamic monitoring during major surgery.
CASE REPORT | doi:10.20944/preprints202302.0023.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: pain; myelomeningocele; paralytic dislocation of the hip; congenital dislocation of the hip; Dega transiliac osteotomy
Online: 2 February 2023 (02:49:13 CET)
Introduction The Pericapsular Nerve Group (PENG) block is a novel technique that allows for analgesia of the anterior hip capsule via the articular branches of the accessory obturator nerve and femoral nerve, which have a significant role in the innervation of the hip capsule. PENG blockade is effective in both adult and pediatric patients. However, there are no studies in the available literature on patients under five years of age. Herein, we describe our experience with two pediatric patients with hip dysplasia. Purpose This study aimed to evaluate the analgesic effect of the pericapsular nerves group (PENG) in small children undergoing hip surgery. Patients and methods This study included two patients, aged 2 and 4 years old, who qualified for hip surgery. General or spinal anesthesia with the addition of a PENG block was performed. During the procedure, the basic hemodynamic parameters were monitored. After the surgery, the patients received 15mg/kg-1 iv paracetamol every 6 hours to prevent rebound pain. The pain was assessed using the FALCC score. The 15mg/kg-1 metamizole was administered if the FLACC score was 3. In the FLACC score 4, the application of 0,2mg/kg-1 Nalpain was ordered. Results The patient's hemodynamic parameters were stable and within normal range. FLACC scores from all patients ranged from 0 and 3 in the first 24 h period. One patient required metamizole 12 hours after surgery. No evidence of block complications was observed. Conclusions This case series showed that PENG block provided adequate postoperative analgesia and assured opioid-free pain management. However, we are convinced that future randomized, controlled trials are needed in this field.
ARTICLE | doi:10.20944/preprints202302.0007.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Facet joint syndrome; adipose tissue-derived regenerative cells
Online: 1 February 2023 (04:40:12 CET)
Background: Chronic Back Pain due to Facet Joint Syndrome is a common and debilitating con-dition. Advances in regenerative medicine have shown that Autologous Unmodified Adipose Tissue-Derived Regenerative Cells (ADRC) provide several beneficial effects [1,2]. These regen-erative cells can differentiate into various tissues  and exhibit a strong anti-inflammatory po-tential. ADRCs can be obtained from a small amount of fatty tissue derived from the patient´s abdominal fat. Methods: We report long-term results of 37 patients (age 31-78 years, mean 62.5) suffering from “Facet Joint Syndrome” The pathology was confirmed by clinical, radiological examinations and fluoroscopically guided test injections. Then liposuction was performed. 50-100 cc of fat were harvested. To recover stem cells from adipose tissue, we use the CE-certified Transpose RT™ system from InGeneron GmbH. The cells were then injected under fluoroscopic control in the periarticular fat. Follow-up examinations were performed at one week 1 and 5 years. Results: Every patient reported improved VAS pain at any follow-up (1 week, 1, and 5 years) with ADRCs compared to the baseline. Conclusion: Our observational data indicate that facet joint syndrome patients treated with unmodified adipose tissue-derived regenerative cells experience improved quality of life in the long term.
ARTICLE | doi:10.20944/preprints202301.0488.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: minimum alveolar concentration MAC; isoflurane; dexmedetomidine; morphine; synthetic cannabinoid WIN 55,212-2; rats
Online: 27 January 2023 (06:16:10 CET)
The effects of morphine (MOR) and dexmedetomidine (DEX) on the MAC of isoflurane were measured in rats chronically treated with the synthetic cannabinoid WIN 55,212-2 (WIN55). Methods: The MAC of isoflurane was determined in 32 male rats from expiratory samples at the time of tail clamping. The effects of morphine (MAC(ISO+MOR)) and dexmedetomidine (MAC(ISO+DEX)) on the MAC of isoflurane in untreated rats and rats treated for 21 days with WIN 55,212-2 (MAC(ISO+WIN55+MOR)) and (MAC(ISO+WIN55+DEX)) were measured. Prior to the administration of morphine and dexmedetomidine, the MAC of the isoflurane was measured in both untreated rats (MAC(ISO)) and those treated with WIN 55,212-2 (MAC(ISO+WIN55)). Results: The minimum alveolar concentration was measured as 1.32 ± 0.06 in the MAC(ISO) group and 1.69 ± 0.09 in the MAC(ISO+WIN55) group. The MAC of the MAC(ISO+MOR) group was 0.97 ± 0.02 (26% less than the control group, MAC(ISO)). MAC was measured as 1.55 ± 0.08 in the MAC(ISO+WIN55+MOR) group (8% less than the MAC(ISO+WIN55) group), 0.68 ± 0.10 in the MAC(ISO+DEX) group (48% less than the control group, MAC(ISO)), and 0.67 ± 0.08 in the MAC(ISO+WIN55+DEX) group (60% less than the MAC(ISO+WIN55) group). Conclusions: The administration of WIN 55,212-2 for 21 days increases the MAC of isoflurane in rats. The sparing effect on isoflurane of morphine decreases in rats chronically treated with the synthetic cannabinoid, WIN 55,212-2. Dexmedetomidine increases its sparing effect on the minimum alveolar concentration of isoflurane in rats chronically treated with WIN 55,212-2.
ARTICLE | doi:10.20944/preprints202211.0575.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Cancer pain; NSAIDs; paracetamol; adverse events
Online: 30 November 2022 (14:11:00 CET)
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for cancer pain. We used Delphi methodology to evaluate the opinions of clinicians on NSAIDs and paracetamol, with a specific focus on their safety profile. Consensus was reached on 7 statements. High level of consensus was reached regarding use of NSAIDs and gastrointestinal, cardiovascular, and renal risk in patients taking low-dose aspirin and assessment of liver function during long-term treatment with paracetamol. Consensus was also reached that assessment and monitoring of eGFR is important in the elderly being administered NSAIDs. It was further agreed that NSAIDs can often play a key role in association with opioids in treatment of cancer pain and that paracetamol is the analgesic of first choice for patients with mild chronic pain. When NSAIDs are administered in combination with steroids, it was agreed that the risk of gastrointestinal damage is increased since steroids delay the healing of ulcers, and that paracetamol can be used during pregnancy and does not affect the health of the fetus. This Delphi study highlights that there is a poor agreement on how these drugs are routinely prescribed. However, the consensus was reached for 7 key statements and may represent a valid contribution to daily practice.
REVIEW | doi:10.20944/preprints202210.0215.v2
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Double lumen tube; Malposition; Thoracic surgery; Airway management; One-lung ventilation; Fiberoptic bronchoscopy; Bibliometric analysis
Online: 23 November 2022 (07:20:57 CET)
The thoracic surgery has increased drastically in recent years, especially in the light of the severe outbreak of 2019 novel coronavirus disease (COVID-19). Routine “passive” chest computed tomography (CT) screening of inpatients detects some pulmonary diseases requiring thoracic surgeries timely. As an essential device for thoracic anesthesia, the double-lumen tube (DLT) is particularly important for anesthesia and surgery. With the continuous upgrading of the DLTs and the widespread use of the fiberoptic bronchoscopy (FOB), the position of DLT in thoracic surgery is gradually becoming more stable and easier to observe or adjust. However, the DLT malposition still occurs during transferring patients from supine to lateral position in thoracic surgery, which leads to lung isolation failure and hypoxemia during one-lung ventilation (OLV). Recently some innovative DLTs or improved intervention methods have shown good results in reducing the incidence of DLT malposition. This review aims to summarize the recent studies of the incidence of left-sided DLT malposition, the reasons and effects of malposition, and summarize current methods for reducing DLT malposition and prospects for possible approaches. Meanwhile, we use bibliometric analysis to summarize the research trends and hot spots of the DLT research.
REVIEW | doi:10.20944/preprints202211.0219.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: TMDs; temporomandibular; TMJ; network meta-analysis; systematic review
Online: 11 November 2022 (07:04:36 CET)
Abstract: Background: Pain management is one of the main parts of treatments for Temporomandibular Disorders (TMDs). However, there is still a lack of high-quality evidence that compare the overall effects of these non-surgical treatments. The objective of this systematic review is to identify the most potential treatment protocol in dealing with pain caused by TMDs through a mixed comparison of interventions based on network meta-analysis. Methods: A systematic review and network meta-analysis of studies identified by searching PubMed, Embase, Medline, Ovid, and CINAHL. All the included studies should have characteristics that: (1) participants with TMDs of any age; (2) non-surgical treatments; (3) score of Visual Analog Scale (VAS) as the outcome measure; (4) randomized controlled trials. The Cochrane Bias Assessment Toll was used to assess the bias, the CINeMA website was applied to rate the confidence of evidence, and ADDIS software was used to conduct the network meta-analysis. Results: 46 studies were included in this review. The agreement between authors reached a kappa value of 0.78. The results of the network meta-analysis showed that wearable therapy devices are more likely to be the best choice for reducing the pain of patients with myogenic TMDs, whereas a combination of platelet-rich plasma injection and wearable therapy devices is more likely to be the best choice for reducing the pain in a long term after treatment for patients with mix-type TMDs. Moreover, the application of therapy equipment has the most potential in reducing pain in a long term after treatment for patients with articular TMDs. Discussion: Wearable devices have a great potential for pain syndrome caused by TMDs, the mechanism might come from a biomechanical perspective. However, the overall confidence rating of evidence is low. Studies with high quality are still needed in the future. Other: The PROSPERO Registration Number of this systematic review is CRD42021253442.
ARTICLE | doi:10.20944/preprints202211.0172.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: airway manikin; apnoeic oxygenation; denitrogenisation; desaturation; oxygen insufflation; test lung
Online: 9 November 2022 (09:05:27 CET)
Background. In a cannot ventilate cannot intubate situation, careful preoxygenation with high FiO2 allowing subsequent apneic oxygenation can be life-saving. The best position for an oxygen supply line within the human airway at which oxygen insufflation is more effective than standard preoxygenation with a face mask, or comparably effective as intratracheal insufflation, is unknown. Methods. In this experimental study, we compared effectiveness of preoxygenation by placing an oxygen cannula at the nose entrance, through the nose at the soft palatine, or at the base of tongue; as control we used ambient air. We connected a fully preoxygenated test lung on one side to an oximeter with a flow rate of 200ml/min simulating oxygen consumption of a normal adult, and on the other side to the trachea of an anatomically correctly shaped airway manikin over a 20 min observation period five times for each cannula placement in random order. Results. Oxygen percentage in the test lung dropped from 100% in all groups to 53±1% in the ambient air control group, to 87±2% in the nasal cannula group, to 96±2% in the soft palatine group, while it remained at 99±1% in the base of tongue group (p=0.003 for soft palatine vs base of tongue; and p<0.001 between all other groups). Conclusions. When simulating apneic oxygenation in a preoxygenated manikin, oxygen insufflation at the base of tongue kept oxygen percentage at baseline values of 99% demonstrating a complete block for ambient air flowing into the manikin’s airway. Oxygen insufflation at the soft palatine or insufflation via nasal cannula were less effective in regard of this effect.
ARTICLE | doi:10.20944/preprints202209.0349.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: isoflurane; schizophrenia; adult neurogenesis; synaptic plasticity; parvalbumin-positive interneuron
Online: 23 September 2022 (02:05:41 CEST)
The therapeutic effects of volatile anesthetics on mental diseases, particularly schizophrenia, have gained considerable interest. Although isoflurane is a commonly used volatile anesthetic, there’s no more evidence that it could work on treating schizophrenia. Here, we discovered that inhaling isoflurane at low concentrations might reverse the behavioral phenotypes of schizophrenia caused by MK801, such as hyperlocomotion, pre-pulse inhibition impairment, and working memory loss. Isoflurane also helped recovering adult neurogenesis and synaptic plasticity impairments in the dentate gyrus (DG) induced by MK801. To better understand the mechanism, we discovered that isoflurane could reverse the reduction of parvalbumin (PV)-positive GABAergic interneuron (PVI) number and the aberration of NRG1-ErbB4 signaling in the DG; however, isoflurane could not reverse the schizophrenia-related phenotypes caused by PVI ablation, indicating that PVI are necessary for the therapeutic effect of isoflurane. Interestingly, isoflurane could reverse phenotypes caused by blocking PVIs GABA release in the DG, indicating the therapeutic impact is independent of PVI GABA release. Our research revealed that isoflurane might be used to treat schizophrenia, possibly through PVI in the DG.
ARTICLE | doi:10.20944/preprints202209.0194.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: opiate; pain; neurotoxicity; misuse
Online: 14 September 2022 (05:55:26 CEST)
Background: Once a widely used analgesic in the United States (US), meperidine offered an alternative to other opioids as a pain reliever. However, within the last two decades, meperidine has gone from a drug to be utilized only when patients exhibit atypical reactions to opioids (e.g., morphine and hydromorphone) to being taken off the World Health Organization List of Essential Medications and receiving strong recommendations for the overall avoidance. The aim of this study was to identify changes in meperidine distribution in the US and regional disparities as reported to the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (DEA ARCOS) and Medicaid. Methods: Data related to the meperidine distribution was obtained through ARCOS (2001 –2021) and Medicaid public use files (2016 –2021). Heat maps were used to visualize regional disparities in distribution by state. States outside a 95% confidence interval were statistically significant. Results: Meperidine distribution between 2001 and 2021 decreased by 97.4% (R=.-97, P < .0001). There was a 34-fold state-level difference in meperidine distribution between Arkansas (16.8 mg/10 persons) and Connecticut (0.5 mg/ 10 persons) in 2020. Meperidine distribution in 2020 was elevated in Arkansas, Mississippi, and Alabama. In 2021, Meperidine distribution was highest in Arkansas ( 1.67 /10 persons) and lowest in Connecticut (0.08 /10 persons). Total prescriptions of meperidine as reported by Medicaid decreased by 73.8% (R= -0.67, P = 0.045) between 2016 and 2021. Conclusion: We observed a decrease in the overall distribution of meperidine in the past two decades with similar recent declines in prescribing to Medicaid enrollees. The shortage of some parenteral formulations is an important contributor to these declines. This data may reflect plans to phase out the use of this opioid, especially in the many situations where preferred opioids are available.
ARTICLE | doi:10.20944/preprints202209.0178.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: chronic postoperative pain; erector spinae plane block; coronary artery bypass grafting; Neuropathic Pain Symptom Inventory
Online: 13 September 2022 (11:24:28 CEST)
Up to 56% of patients develop chronic postsurgical pain (CPSP) after coronary artery bypass grafting (CABG). CPSP can affect patients’ moods and decrease daily activities. The primary aim of this study was to investigate CPSP severity in patients following off-pump (OP)-CABG using the Neuropathic Pain Symptom Inventory (NPSI). This was a prospective cohort study conducted in a cardiac surgery department of a teaching hospital. Patients undergoing OP-CABG were enrolled in an erector spinae plane block (ESPB) group (n = 27) or a control (CON) group (n = 24). Before the induction of general anesthesia, ESPB was performed on both sides under ultrasound guidance using 0.375% ropivacaine. The secondary outcomes included cumulative oxycodone consumption, acute pain intensity, mechanical ventilation time, hospital length of stay, and postoperative complications. CPSP intensity was lower in the ESPB group than in the CON group 1, 3, and 6 months postsurgery (p < 0.001). Significant between-group differences were also observed in other outcomes, including postoperative pain severity, opioid consumption, mechanical ventilation time, and hospital length of stay in favor of the ESPB group. Preemptive ESPB appears to decrease the risk of CPSP development in patients undergoing OP-CABG. Reduced acute pain severity and shorter mechanical ventilation times and hospital stays should improve patients’ satisfaction and reduce perioperative complications.
ARTICLE | doi:10.20944/preprints202209.0043.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: anaesthesia; workforce challenges; qualitative research; Pakistan
Online: 5 September 2022 (04:30:46 CEST)
Global anaesthesia workforce limitations contribute to emigration of skilled anaesthesiologists from lower- to higher-income countries, jeopardizing workforce balance and patient outcomes in Pakistan. This study aims to explore challenges experienced by anaesthesiologists in Punjab, Pakistan’s most populous province, and necessary changes to encourage their retention. We conducted a qualitative study to examine perspectives of anaesthesiologists who chose to serve in Pakistan. We drew data from semi-structured interviews conducted with 25 purposively-sampled consultant anaesthesiologists. We analysed data thematically and distinguished the practice hurdles faced by anaesthesiologists in public and private hospitals of Punjab. The main reasons to work abroad could be broadly categorized under two inductive themes, i.e. practice hurdles in public and private sector. Both had distinct issues which compromised the number and quality of anaesthesia workforce in the country. The key outcomes were workplace security, promotion/incentive issues and gender inequalities in the government sector. The private sector had improper salaries and facilities, anaesthesiologist’s dependency on surgeons for getting work and lack of out-of-theatre practice which minimise the scope and earnings of anaesthesiologist within the country. There is a need to overcome surgeon dependency and hospital manipulation by fixing salary percentages for each surgical case and encouraging direct patient-anaesthesiologist relationships.
CASE REPORT | doi:10.20944/preprints202208.0453.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: electrocardiogram; pulmonary hypertension; right axis deviation; dextrocardia; technical errors
Online: 26 August 2022 (09:27:06 CEST)
A 57-year-old male with a history of hyperlipidemia and mild pulmonary hypertension presented for a left inguinal hernia repair. Preoperative electrocardiogram showed severe right axis deviation at 177 degrees and abnormal repolarization. Right ventricular hypertrophy secondary to pulmonary hypertension was the primary differential but was quickly ruled out due to the patient being asymptomatic and having great exercise tolerance. Dextrocardia was also ruled out due to normal progression on the precordial leads. The simultaneous severe right axis deviations of P, R, and T waves raised suspicion for erroneous lead placement. The repeat electrocardiogram confirmed the diagnosis.
ARTICLE | doi:10.20944/preprints202208.0447.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: low-back pain (LBP); guidelines; gaps; evidence-based; acute pain; analgesics; multimodal analgesia; fixed doses combination (FDC)
Online: 26 August 2022 (04:36:13 CEST)
Acute low back pain (LBP) stands as a leading cause of activity limitation and work absenteeism, and its associated healthcare expenditures are expected to become substantial when acute LBP develops into a chronic and even refractory condition. Therefore, early intervention is crucial to prevent progression to chronic pain whose management is particularly challenging and for which the most effective pharmacological therapy is still controversial. Current guideline treatment recommendations vary and are mostly driven by expertise with opinion differing across different interventions. Thus, it is difficult to formulate evidence-based guidance when relatively few randomized clinical trials did explore the diagnosis and management of LBP while employing different selection criteria, statistical analyses, and outcome measurements. This narrative review aims to provide a critical appraisal of current acute LBP management by discussing the unmet needs and areas of improvement from bench-to-bedside and proposes multimodal analgesia as the way forward to attain an effective and prolonged pain relief and functional recovery in patients with acute LBP.
REVIEW | doi:10.20944/preprints202208.0141.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: hemorrhagic shock; multimodal monitoring; individualized therapy; fluid therapy; critical care; trauma
Online: 8 August 2022 (09:56:33 CEST)
Worldwide, one of the main causes of death among young adults is multiple trauma. In these pa-tients hemorrhagic shock represents the leading cause for worsening of the clinical status and for increased morbidity and mortality. This is due to a multifactorial complex involving cellular, bi-ological, and biophysical mechanisms. The most important mechanisms affecting clinical out-come are oxidative stress, the augmentation of pro-inflammatory status, immune deficiency, dis-ruptions in the coagulation cascade, imbalances in electrolyte and acid-base homeostasis. Poly-trauma patients in hemorrhagic shock need adequate fluid management to ensure hemodynamic stability that must consider not only the maintenance of adequate blood pressure, but also the ad-equate oxygenation of tissues for optimal cellular function. In the current clinical practice, fluid resuscitation in polytrauma patients uses a variety of widely studied pharmacological products, such as crystalloids, colloids, blood transfusions, and the infusion of other blood products. Alt-hough these products exist, an agreement was not reached on a standard administration protocol that could be generally applied for all patients. Moreover, numerous studies have reported a se-ries of adverse events related to fluid resuscitation and to the inadequate use of these products. This review aims at describing the impact the administration of all the solutions used in fluid re-suscitation might have on the cellular and pathophysiological mechanisms in the case of poly-trauma patients suffering from hemorrhagic shock.
ARTICLE | doi:10.20944/preprints202207.0361.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: PSPS; FBSS; SCS; surgical lead; SCS implantation; MAST (for Minimal Access Spine Technologies); TCIVA (for Target Controlled Intra-Veinous Anesthesia); composite score; pain mapping; neuropathic pain; chronic pain; quality of life; anesthesia; hypnosis
Online: 25 July 2022 (08:34:26 CEST)
Spinal Cord Stimulation (SCS) is an effective and validated treatment to address chronic refractory neuropathic pain in Persistent Spinal Pain Syndrome-Type 2 (PSPS-T2) patients. Surgical SCS lead placement is traditionally performed under general anesthesia due to its invasiveness. In parallel, recent works have suggested that Awake Anesthesia (AA), consisting in Target Controlled Intra-Veinous Anesthesia (TCIVA), could be an interesting tool to optimize lead anatomical placement using patient intra-operative feedback. We hypothesized that combining AA with Minimal Invasive Surgery (MIS) could improve SCS outcomes. The goal of this study was to evaluate SCS lead performance (defined by the area of pain adequately covered by paraesthesia generated via SCS), using an intraoperative objective quantitative mapping tool, and secondarily to assess pain relief, functional improvement and change in quality of life with a composite score. We analyzed data from a prospective multicenter study (ESTIMET) to compare the outcomes of 115 patients implanted with MIS under AA (MISAA group) or General Anesthesia (MISGA group), or by Laminectomy under General Anesthesia (LGA group). All in all, MISAA appears to show significantly better performance in terms of patient pain coverage, as well as improved secondary outcomes. One step further, our results suggest that MISAA combined with intra-operative hypnosis could potentialize patient intraoperative cooperation and could be proposed as a personalized package offered to PSPS-T2 patients eligible for SCS implantation in highly dedicated neuromodulation centers.
COMMUNICATION | doi:10.20944/preprints202206.0258.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: desflurane; cardiac surgery; halogenated; kidney; heart; preconditioning
Online: 20 June 2022 (04:52:02 CEST)
Introduction: The effect of halogenated drugs as cardioprotectors in cardiac surgery has been evaluated in several studies. However, the possibility that there is a protective role at renal level, triggered by their use, is currently under study. Aortic valve replacement and coronary revascularization are the most frequent surgeries in cardiac surgery. Our research evaluates the effect of desflurane compared to propofol in aortic valve replacement surgery at renal level; including its administration during extracorporeal circulation. Method: Quasi-experimental prospective study performed on 60 patients, divided into 2 groups according to the drug used in intraoperative aortic valve replacement surgery. In group 1 propofol was used as a hypnotic during surgery, in group 2 desflurane was used. Differences in kidney damage measured through the urinary NGAL marker were evaluated. Other markers of renal function and myocardial damage and the need for inotropic support during the first 48 hours were also measured. Results: There were significant variations in the values of urinary NGAL and creatinine regarding to basal values in the propofol group, but not in the desflurane group, in which there were no differences in the hemodynamic parameters and myocardial damage. Conclusion: the use of desflurane during aortic valve replacement surgery produced better renal preservation than propofol.
ARTICLE | doi:10.20944/preprints202203.0339.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Neuralgia; Interventional Pain Management; Intractable Pain; Delphi Technique; Review
Online: 25 March 2022 (07:41:03 CET)
Interventional management of neuropathic pain (NP) is available to the many patients who do not attain satisfactory outcomes with pharmacotherapy, but evidence supporting this is sparse and fragmented. We attempted to summarize and critically appraise the existing data to identify strategies that yield maximum benefit, orient clinicians, and identify areas that merit further investigation. A two-round Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 26-item questionnaire prepared by the authors. Consensus on each statement was defined as either at least 80% endorsement or rejection after the second round. Thirty-five and 29 panelists participated in the first and second round, respectively. Consensus was reached in 20 out of 26 statements. There is sufficient basis to treat postherpetic neuralgias and complex regional pain syndromes with progressive levels of invasiveness and failed back surgery syndrome with neuromodulation. Radiculopathies and localized NP could be treated with peripheral blocks and neuromodulation, or pulsed radiofrequency. Non-ablative radiofrequency and non-paresthetic neuromodulation are efficacious and better tolerated than ablative and suprathreshold procedures. A graded approach, from least to most invasive interventions has the potential to improve outcomes in many patients with common refractory NP conditions. Preliminary promising data warrant further research on new indications, and technical advances might enhance the safety and efficacy of current and future therapies.
ARTICLE | doi:10.20944/preprints202202.0273.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: MAC; Isoflurane; WIN 55,212-2; Rat
Online: 22 February 2022 (11:28:05 CET)
Background: The isoflurane minimum alveolar concentration (MAC) was measured in rats chronically treated with WIN 55,212-2. Methods: The isoflurane MAC was determined in 24 male rats from the end expiratory samples at time of tail clamping under the following conditions: without treatment (MACISO), in rats treated for 21 days with WIN 55,212-2 (MACISO+WIN55) and other group 8 days after stopping treatment for 21 days with WIN 55,212-2 (MACISO+WIN55+8D). Results: The MACISO was 1.32 ± 0.06. In the MACISO+WIN55 group the MAC increase to 1.69 ± 0.09 (28%). After 8 days stopping treatment, MAC did not decrease significantly 1.67 ± 0.07 (26%). Conclusions: The administration for 21 days of WIN 55,212-2 increases the MAC of isoflurane in rats; this effect does not disappear after 8 days of discontinuing treatment with the synthetic cannabinoid.
ARTICLE | doi:10.20944/preprints202201.0116.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Ischaemia/reperfusion injury; Development; Mitochondria; Immature Heart
Online: 10 January 2022 (13:38:07 CET)
Metabolic and ionic changes during ischaemia predispose the heart to the damaging effects of reperfusion. Such changes and the resulting injury differ between immature and adult heart. Therefore, cardioprotective strategies for adults need to be tested in immature heart. We have recently shown that simultaneous activation of PKA and EPAC confers marked cardioprotection in adult hearts. The aim of this study is to investigate the efficacy of this intervention in immature hearts and determine whether the mitochondrial permeability transition pore (MPTP) is involved. Isolated perfused Langendorff hearts from both adult and immature rats were exposed to global ischaemia and reperfusion injury (I/R) following control perfusion or perfusion after an equilibra-tion period with activators of PKA and/or EPAC. Functional outcome and reperfusion injury were measured and in parallel, mitochondria were isolated following 5 min reperfusion to determine whether cardioprotective interventions involved changes in MPTP opening behaviour. Perfusion for 5 minutes preceding ischaemia of injury- matched adult and immature hearts with 5 µM 8-Br (8-Br-cAMP-AM), an activator of both PKA and EPAC, led to significant reduction in post-reperfusion CK release and infarct size. Perfusion with this agent also led to a reduction in MPTP opening propensity in both adult and immature hearts. These data show that immature hearts are innately more resistant to I/R injury than adults, and that this is due to a reduced ten-dency to MPTP opening following reperfusion. Further, simultaneous stimulation of PKA & EPAC causes cardioprotection which is additive to the innate resistance.
REVIEW | doi:10.20944/preprints202112.0468.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: aging; elderly; pain; opioids; dementia; cognitive impairment
Online: 29 December 2021 (13:42:02 CET)
Background: Assessment and management of pain in elderly people with cognitive impairment is particularly challenging. Physiological changes due to aging as well as comorbidities and polypharmacy are responsible for a complex clinical approach. Concomitantly, in cognitive impairment, including advanced dementia, changes in central nervous system along with changes in the peripheral nervous system due to aging have a significant impact in pain perception. Often clinicians decide to prescribe opioids in order to relief pain, also without a clear indication. Aim: This review aims to investigate the effect of opioids in elderly patients with cognitive impairment. Methods: A literature search of PubMed/Medline, Scopus, and Cochrane databases was conducted using keyword searches to generate lists of articles which were screened for relevance by title and abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. Results: This review discuss the complex physiological and pharmacological changes in elderly as well as the neurological changes that affect pain perception in this population. Additionally, it focuses on cognitive impairment and pain in Alzheimer’s disease and other dementias, the pain assessment in the elderly with cognitive impairment as well as the safety of opioid use in elderly. Information regarding opioid prescription in nursing homes as well as recorded indications for opioids use, type and dosing of opioid and compliance of treatment in advanced dementia are also provided. Conclusions: Opioid prescription in elderly population with cognitive impairment is particularly complex. All healthcare professionals involved in the care of such patients, need to be aware of the challenges and strive to ensure analgesic use is guided by appropriate and accurate pain assessment.
CASE REPORT | doi:10.20944/preprints202110.0386.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Atelectasis; Hypoxia; Old age; Spontaneous respiration
Online: 26 October 2021 (12:36:47 CEST)
There are several causes of hypoxia during and after surgery, and atelectasis is a common symptom that occurs during surgery. In particular, elderly patients are more vulnerable to hypoxia due to their existing lung diseases or respiratory muscle weakness. This study presents the cases of two elderly patients who developed hypoxia during total hip arthroplasty under general anesthesia. Positive end expiratory pressure, recruitment maneuver, and increased fraction of inspired oxygen improved hypoxia only temporarily, and patients’ oxygen saturation level again dropped to 79%–80%. We suspected that hypoxia was caused by atelectasis and, therefore, re-sumed spontaneous respiration. Thereafter, both the patients showed an improvement in hypoxia. Intraopera-tive hypoxia that is suspected to be caused by atelectasis can be improved by securing sufficient lung volume for respiration through increased muscle tone with spontaneous respiration
ARTICLE | doi:10.20944/preprints202110.0339.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Drosophila melanogaster; TBI; obesity; volatile anesthetics; isoflurane; sevoflurane; preconditioning; mortality; toxicity
Online: 25 October 2021 (10:28:33 CEST)
We tested the hypothesis that obesity influences the pharmacodynamics of volatile general anesthetics (VGAs) by comparing effects of anesthetic exposure on mortality from traumatic brain injury (TBI) in lean and obese Drosophila melanogaster. We induced TBI with a High-Impact Trauma device. Starvation-selection over multiple generations resulted in an obese phenotype (SS flies). Fed flies served as lean controls (FC flies). Adult (1-7 day old) SS and FC flies were exposed to equianesthetic doses of isoflurane or sevoflurane either before or after TBI. The principal outcome was percent mortality 24 hours after injury, expressed as the Mortality Index at 24 hours (MI24). TBI resulted in lower MI24 in FC than in SS flies (21 (2.35) and 57.8 (2.14), respectively n= 12, p=0.0001). Preexposure to isoflurane or sevoflurane preconditioned FC flies to TBI reducing the risk of death to 0.53 [0.25 to 1.13] and 0.82 [0.43 to 1.58], respectively, but had no preconditioning effect in SS flies. Postexposure to isoflurane or sevoflurane increased the risk of death in SS flies. Only postexposure to isoflurane increased the risk in FC flies (1.39 [0.81 to 2.38]). Thus, obesity affects the pharmacodynamics of VGAs, thwarting the preconditioning effect of isoflurane and sevoflurane in TBI.
ARTICLE | doi:10.20944/preprints202109.0010.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: spinal cord stimulation; screening trial; infection; supervised learning; machine learning; predictive modeling; patient outcome
Online: 1 September 2021 (12:05:18 CEST)
Persistent Pain after Spinal Surgery can be successfully addressed by Spinal Cord Stimulation (SCS). International guidelines strongly recommend that a lead trial be performed before any permanent implantation. Recent clinical data highlight some major limitations of this approach. First, it appears that patient outcomes, WITH OR WITHOUT lead trial, are similar. In contrast, during trialing, infection rate drops drastically within time and can compromise the therapy. Using composite pain assessment experience and previous research, we hypothesized that ma-chine learning models could be robust screening tools and reliable predictors of long-term SCS efficacy. We developed several algorithms including logistic regression, Regularized Logistic Regression (RLR), naive Bayes classifier, artificial neural networks, random forest and gradient boosted trees to test this hypothesis and to perform internal and external validations, the objec-tive being to confront model predictions with lead trial results using a 1-year composite out-come from 103 patients. While almost all models have demonstrated superiority on lead trial-ing, the RLR model appears to represent the best compromise between complexity and inter-pretability in prediction of SCS efficacy. These results underscore the need to use AI based-predictive medicine, as a synergistic mathematical approach, aimed at helping implanters to optimize their clinical choices on daily practice.
ARTICLE | doi:10.20944/preprints202108.0545.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Composite score; Machine learning; PSPS; Failed Back Surgery Syndrome (FBSS); Chronic pain; Pain Intensity; Quality of Life; Pain Mapping; Pain Surface; Functional Capacity; Psychological Distress; Anxiety and Depression
Online: 30 August 2021 (13:04:51 CEST)
The multidimensionality of chronic pain forces us to look beyond isolated pain assessment such as pain intensity, which does not consider multiple key parameters, particularly in patients suffering from post-operative Persistent Spinal Pain Syndrome (PSPS-T2). Our ambition was to provide a novel Multi-dimensional Clinical Response Index (MCRI), including not only pain intensity but also functional capacity, anxiety-depression, quality of life and objective quantitative pain mapping assessments, the objective being to capture patient condition instantaneously, using machine learning techniques. Two hundred PSPS-T2 patients were enrolled in a real-life observational prospective PREDIBACK study with 12-month follow-up and received various treatments. From a multitude of questionnaires/scores, specific items were combined using exploratory factor analyses to create an optimally accurate MCRI; as a single composite index, using pairwise correlations between measurements, it appeared to better represent all pain dimensions than any other classical score. It appeared to be the best compromise among all existing indexes, showing the highest sensitivity/specificity related to Patient Global Impression of Change (PGIC). Novel composite indexes could help to refine pain assessment by changing the physician’s perception of patient condition on the basis of objective and holistic metrics, and by providing new insights to therapy efficacy/patient outcome assessments, before ultimately being adapted to other pathologies.
COMMUNICATION | doi:10.20944/preprints202010.0085.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Cardiothoracic Surgery; Anesthesia Staffing Models; Outcomes; Operating Room Staffing; Handoffs; Quality; Communication
Online: 5 October 2020 (12:55:52 CEST)
The operating room in a cardiothoracic surgical case is a complex environment, with multiple handoffs often required by staffing changes, and can be variable from program to program. This study was done to characterize what types of practitioners provide anesthesia during cardiac operations to determine the variability in this aspect of care. A survey was sent out via a list serve of members of the cardiac surgical team. Responses from 40 programs from a variety of countries showed variability across every dimension requested of the cardiac anesthesia team. Given that anesthesia is proven to have influence on the outcome of cardiac procedures, this study indicates the opportunity to further study how this variability influences outcomes, and to identify best practices.
REVIEW | doi:10.20944/preprints202007.0568.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: SARS-CoV-2; COVID-19; respiratory failure; ARDS; ventilation; MODS; ECMO
Online: 24 July 2020 (04:00:50 CEST)
The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a significant surge of critically ill patients and an unprecedented demand on intensive care services. The rapidly evolving understanding of pathogenesis, limited disease specific evidence and demand-resource imbalances have posed significant challenges for intensive care clinicians. COVID-19 is a complex multisystem inflammatory vasculopathy with a significant mortality implication for those admitted to intensive care. Institutional strategic preparation and meticulous intensive care support are essential to maximising outcomes during the pandemic. The significant mortality variation observed between institutions and internationally, despite a single aetiology and uniform presentation, highlights the potential influence of management strategies on outcome. Given that optimal organ support and adjunctive therapies for COVID-19 have not yet been well defined by trial-based outcomes, strategies are predicated on existing literature and experiential learning. This review outlines the relevant pathophysiology and management strategies for critically ill patients with COVID-19, and shares some of the collective learning accumulated in a high volume Severe Respiratory Failure centre in London.
REVIEW | doi:10.20944/preprints202007.0426.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: COVID-19; ARDS; Adenosine; CT-scan; Cytokines Storm
Online: 19 July 2020 (19:31:13 CEST)
Some COVID-19 patients develop interstitial pneumonia that can evolve into Acute Respiratory Distress Syndrome (ARDS). This is accompanied by an inflammatory cytokine storm. SarS-CoV has proteins capable of promoting cytokine storm, especially in patients with comorbidities, including obesity. Since there is currently no resolutive therapy for ARDS and given the scientific literature regarding the use of adenosine, its application has been hypothesized. Adenosine through its receptors is able to inhibit the acute inflammatory process, increase the protection capacity of the epithelial barrier and reduce the damage due to an overactivation of the immune system, such as in cytokine storms. These features are known in ischemia / reperfusion models and could also be exploited in acute lung injury, with hypoxia. In light of these hypotheses, for compassionate use, a COVID-19 patient, with unresponsive respiratory failure, was treated with adenosine. The results showed a rapid and clear improvement in clinical conditions, with the negative effect of detection of SarS-CoV2.
ARTICLE | doi:10.20944/preprints202007.0303.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Lower back pain; automated tool; ML; ensemble technique; stacked generalization
Online: 14 July 2020 (11:31:46 CEST)
Lower Back Pain (LBP) is a disease that needs immediate attention. Person with back pain shall go immediately to doctor for treatment. Injury, excessive works and some medical conditions are result of back pain. Back pain is common to any age of human for different reasons. Due to factors such as previous occupation and degenerative disk disease the chance of developing lower back pain increases for older people. It hampers the working condition of people common reason for seeking medical treatment. The result is absence from work and is unable to normal due to pain. It creates uncomfortable and debilitating situations. Hence, detecting this disease at an early stage will assist the medical field experts to suggest counter measures to the patients. Detection of lower back pain is implemented in this paper by applying ensemble machine learning technique. This paper proposes Stacking ensemble classifier as an automated tool that will predict lower back pain tendency of a patient. Experimental result implies that the proposed method reaches an accuracy of 76.34%, f1-score of 0.76 and MSE of 0.34.
ARTICLE | doi:10.20944/preprints202006.0029.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: COVID-19; ethnicity; BAME; deprivation
Online: 4 June 2020 (08:03:48 CEST)
On the 9th March 2020, the first patient with COVID-19 was admitted to ICU in the Royal Gwent Hospital, Newport, Wales. We prospectively recorded the rate of ICU admissions of 52 patients with COVID-19 over 60 days, focusing on the epidemiology of ethnicity and deprivation. Patients were 65% (34 of 52) male and had a median (IQR) age of 55 (48-62) years. Prevalent comorbidities included obesity (52%); diabetes (33%), and asthma (23%). COVID-19 hospital and ICU inpatient numbers peaked on days 23 and 39, respectively – a lag of 16 days. The ICU mortality rate was 33% (17 of 52). Black, Asian and Minority Ethnics (BAME) population represented 35% of ICU COVID-19 admissions (18 of 52) and 35% of deaths (6 of 17). Within the BAME group, 72% (13 of 18) were found to reside in geographical areas representing the 20% most deprived in Wales, versus 27% of Caucasians (9 of 33). Less than 5% of the population within the hospital catchment area are of BAME descent, yet they represent a disproportionately high proportion of patients with ICU admission and mortality suffering from COVID-19. The interplay between ethnicity and deprivation, which is complex, may be a factor in our findings. This in turn could be related to an increased prevalence of co-morbidities; higher community exposure; or genetic polymorphisms.
CONCEPT PAPER | doi:10.20944/preprints202005.0373.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: COVID-19; proteolytic cascades; thrombosis; viral sepsis
Online: 23 May 2020 (10:42:38 CEST)
Based on Chinese CDCP report on COVID-19, 14% of patients presented severe disease and 5% critical conditions. The average case-fatality rate was 2.3%, but mortality was as high as 49% in patients with critical illness. Serious life threatening thromboembolic complications have been found in 71·4% of non-survivors and micro/macro angiopathic coagulopathy has been found, also at autopsy, with highly increased neutrophil number, fibrinogen, concentrations of D-dimer and FDPs and NETs, ATIII decrease and normal number of platelets. A cytokine storm and interaction between inflammation and coagulation has been advocated as explanation of hypercoagulability. In this paper, it’s hypothesised that SARS-CoV-2 infection of alveolar cells induces recruitment of innate responder neutrophils, which release proteases and NETs inducing endothelial damage/endotheliopathy and imbalance of the four major proteolytic cascades (coagulation, complement, fibrinolysis and kallikrein) with prevalence of activators over inhibitors and consequent thrombotic complications. Platelets adhesion to damaged endothelium and the presence of ULVWF multimers, due to decreased ADAMTS13, contributes to the state of hypercoagulability. Neutrophil innate “unfriendly fire” response can be identified as the trigger of a “proteolytic storm”, responsible for subsequent well known prothrombotic condition and “cytokine storm”. The hypothesis explains also the pathology of recently described systemic “Kawasaki Disease like” vasculitis cases in Covid-19 young ill patients.
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Covid-19; airway extubation; aerosols; laryngeal masks; occupational health
Online: 7 April 2020 (12:33:07 CEST)
We report smooth weaning from mechanical ventilation in a patient with COVID-19. The use of the supraglottic airway device can cause fewer coughs in weaning from mechanical ventilation. This procedure avoids the aerosol-generating procedure, tracheal extubation, and is beneficial in terms of occupational health for health care workers.
ARTICLE | doi:10.20944/preprints202003.0116.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: continuous epidural infusion; dexamethasone; dexamethasone pulse therapy; inflammation; local anesthetics; neuropathic pain; postherpetic neuralgia
Online: 7 March 2020 (03:22:47 CET)
The most common complication of herpes zoster is postherpetic neuralgia (PHN), which is accompanied by severe pain that lowers patients’ quality of life. Although epidural injection of local anesthetics and steroids is effective in controlling neuropathic pain resulting from herpes zoster, few studies report the efficacy and safety of epidural steroid administration in PHN patients. We randomly assigned 42 patients with severe PHN pain (visual analog scale (VAS) score ≥7) to receive continuous epidural infusion of local anesthetics with either a one-time bolus of 5 mg dexamethasone or dexamethasone pulse therapy. VAS scores significantly decreased over time for all patients, but the reduction in VAS scores and likelihood of achieving complete remission were significantly greater among patients who received dexamethasone pulse therapy, without any adverse effects. These results show that continuous epidural infusion of local anesthetics with dexamethasone is effective and safe for reducing PHN pain and promoting complete remission and that more pronounced beneficial effects are associated with more intense epidural steroid administration.
REVIEW | doi:10.20944/preprints202003.0020.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: visual patient; patient monitoring; avatar-based technology; situation awareness; user-centered design
Online: 2 March 2020 (00:56:03 CET)
Visual Patient technology is a situation awareness–oriented visualization technology that translates numerical and waveform patient monitoring data into a new user-centered visual language. Vital sign values are converted into colors, shapes, and rhythmic movements—a language humans can easily perceive and interpret—on a patient avatar model in real time. In this review, we summarize the current state of the research on the Visual Patient, including the technology, its history, and its scientific context. We also provide a summary of our primary research and a brief overview of research work on similar user-centered visualizations in medicine. In several computer-based studies under various experimental conditions, Visual Patient transferred more information per unit time, increased perceived diagnostic certainty, and lowered perceived workload. Eye tracking showed the technology worked because of the way it synthesizes and transforms vital sign information into new and logical forms corresponding to the real phenomena. The technology could be particularly useful for improving situation awareness in settings with high cognitive demand or when users must make quick decisions. This comprehensive review of Visual Patient research is the foundation for an evaluation of the technology in clinical applications, starting with a high-fidelity simulation study in early 2020.
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: effective anesthesia; earthquake; orthopedic; victim’s management
Online: 25 February 2020 (12:14:03 CET)
Lombok earthquake that occurred in July 2018 has three large magnitude earthquakes that caused huge losses; 564 victims died, 1684 injured, 445 343 refugees, and 215 628 houses were damaged. The role of anesthesiology is very important to give prompt therapy for injured victims. This research gave an overview of the important role of Anesthesiologist and the selection of anesthesia techniques during the natural disasters’ victims’ management. This study was conducted by collecting data of all earthquake victims treated at the emergency room (ER) of RSUD NTB on August 6th and 7th 2018 and all victims operated during August 5 – 25th 2018. All data were recorded, analyzed, and presented in descriptive form using frequency, pie chart, and bar diagrams. The result shown that the highest number of patients treated in ER are during the first seven days after the earthquake and reduced to several weeks. The majority of patients treated are trauma patients who need orthopedic surgery. Since limited number of anesthesiologist should be considered with the right selection of anesthesia techniques, so that the disaster preparedness could be prepared well and the disaster management could run well. General anesthesia was widely used than regional anesthesia, but the different is not significant. The type of regional anesthetic drug usually used is lidodex in combination with catapres. The role of anesthesiologist during disaster is important to handle a safe and optimal surgical condition.
ARTICLE | doi:10.20944/preprints202002.0186.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: breakthrough cancer pain; cancer-associated pain; cancer; health-related quality of life; sleep disorders; transmucosal fentanyl
Online: 14 February 2020 (03:36:53 CET)
Objectives: To explore the effect of breakthrough cancer pain (BTcP) treatment on quality of sleep and other aspects of the health-related quality of life (HRQoL) in patients with cancer pain. Methods: In an observational, multicenter, cohort study, cancer patients from palliative care units, oncology departments, and pain clinics and affected by BTcP were included. Enrolled patients were assessed at the four visits: T0 (baseline), T7, T14, and T28. Well-controlled chronic background pain during the whole study period was mandatory. BTcP was treated through transmucosal fentanyl. Three questionnaires were used to measure the HRQoL: EORTC QLQ-C15-PAL, Pittsburgh Sleep Quality Index (PSQI), and the Edmonton Symptom Assessment System (ESAS). Results: In 154 patients, the HRQoL showed a significant improvement for all physical and emotional characteristics in the EORTC QLQ-C15-PAL, except for nausea and vomiting (Linear p-value = 0.1) and dyspnoea (Linear p-value =0.05). The ESAS and PSQI questionnaires confirmed these positive results (p<0.0001 and p=0.002, respectively). Conclusions: This prospective investigation by an Italian expert group, has confirmed that careful management of BTcP induces a paramount improvement on the HRQoL. Because in cancer patients there is a high prevalence of BTcP and this severe acute pain has deleterious consequences, this information can have an important clinical significance
ARTICLE | doi:10.20944/preprints202002.0130.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: state entropy; response entropy; general anaesthesia; patient safety; recovery.
Online: 10 February 2020 (15:24:34 CET)
Study background and aims: Laparoscopic cholecystectomy is one of the most frequently performed interventions in departments of general surgery. One of the most important aims in achieving perioperative stability of these patients is diminishing the impact of general anesthesia on the hemodynamic stability and the optimization of anesthetic drug doses based on the individual clinical profile of each patient. The objective of this study is the evaluation of the impact monitoring the depth of anesthesia through Entropy (state entropy – SE and response entropy -RE) has on the hemodynamic stability and on the doses of volatile anesthetic. Material and Methods: This is a prospective, observational, randomized, monocentric study carried out between January 2019 and December 2019 in the Clinic of Anesthesia and Intensive Care from the “Pius Brînzeu” Emergency County Hospital in Timișoara, Romania. The patients included in the study were divided in two study groups; patients in Group A (target group) received multimodal monitoring that included monitoring of standard parameters and of Entropy (SE and RE), while patients in Group B (control group) only received standard monitoring. Anesthetic dose in group A were optimized to achieve a target entropy of 40-60. Results: 68 patients met the inclusion criteria and were allocated to one of the two study groups, Group A (N=43) and Group B (N=25). There were no statistically significant differences identified between the two groups for both demographical and clinical data (p>0.05). Statistically significant differences have been identified for the number of hypotensive episodes (p = 0.011, 95% CI 0.1851 to 0.7042) and for the number of episodes of bradycardia (p < 0.0001, 95% CI 0.3296 to 0.7923). Moreover, there was a significant difference in the Sevoflurane consumption between the two study groups (p = 0.0498, 95% CI -0.3942 to 0.9047). Conclusions: The implementation of the multimodal monitoring protocol that includes the standard parameters and the measurement of Entropy for determining the depth of anesthesia (SE and RE) lead to a considerable improvement in perioperative hemodynamic stability. Optimizing the doses of anesthetic drugs based on the individual clinical profile of each patient leads to a considerable decrease in drug consumption as well as to a lower incidence of hemodynamic side-effects.
ARTICLE | doi:10.20944/preprints202002.0093.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Ketamine; Paravertebral block; Posterolateral thoracotomy; Thoracotomy; Visual analog scale
Online: 7 February 2020 (09:28:16 CET)
Severe postoperative pain affects most patients after thoracotomy and is a risk factor for post-thoracotomy pain syndrome (PTPS). This randomized controlled trial compared preemptively administered ketamine versus paravertebral block (PVB) versus control in patients undergoing posterolateral thoracotomy. The primary outcome was acute pain intensity on the visual analog scale (VAS) on the first postoperative day. Secondary outcomes included morphine consumption, patient satisfaction, and PTPS assessment with Neuropathic Pain Syndrome Inventory (NPSI). Acute pain intensity was significantly lower with PVB compared to other groups at four out of six time points. Patients in the PVB group used significantly less morphine via a patient-controlled analgesia pump than participants in other groups. Moreover, patients were more satisfied with postoperative pain management after PVB. PVB, but not ketamine, decreased PTPS intensity at 1, 3, and 6 months after posterolateral thoracotomy. Acute pain intensity at hour 8 and PTPS intensity at month 3 correlated positively with PTPS at month 6. Bodyweight was negatively associated with chronic pain at month 6. Thus, PVB but not preemptively administered ketamine decreases both acute and chronic pain intensity following posterolateral thoracotomies. The trial was prospectively registered at the Australian New Zealand Clinical Trial Registry (https://www.anzctr.org.au/; ACTRN12616000900415; 07 July 2016).
ARTICLE | doi:10.20944/preprints201912.0378.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: blood viscosity; transit-time flow measurement; coronary artery bypass surgery
Online: 29 December 2019 (10:22:23 CET)
Background: Transit-time flow measurement (TTFM) is frequently used to evaluate intraoperative quality control during coronary artery bypass grafting (CABG). Although TTFM has the ability to assess graft failure intraoperatively, the perioperative factors affecting TTFM during CABG surgery remain poorly understood. Methods: Patients who underwent CABG surgery at a single institution between July 2016 and May 2018 were prospectively evaluated. Patients’ demographic characteristics, previous medical history, Euroscore, the results of preoperative blood tests, and intraoperative data were recorded. TTFM and blood viscosity were measured hemodynamically, and mean flow (mL/min) and pulsatility index (PI) were recorded. Arterial blood gas was analyzed immediately after anastomosis of the left internal mammary artery (LIMA) to the left descending artery (LAD) and before sternal closure. Factors associated with TTFM were assessed by multiple linear regression analysis. Results: Of the 62 patients who underwent CABG surgery during the study period, 57 were evaluated, including 49 who underwent off-pump and eight who underwent on-pump surgery. Blood viscosity was not significantly associated with TTFM (p > 0.05). However, TTFM was significantly associated with body mass index (BMI), systolic blood pressure, and cardiac index (p < 0.05 each). Conclusions: Blood viscosity was not significantly associated with intraoperative graft flow. Blood flow of graft vessels, however, was significantly associated with BMI, systolic blood pressure, and cardiac index.
ARTICLE | doi:10.20944/preprints201911.0101.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: chronic pain; epigenetics; neuropathic pain; postoperative pain; thoracic surgery; video-assisted
Online: 10 November 2019 (09:29:13 CET)
Background: Elucidation of epigenetic mechanisms correlating with neuropathic pain in humans is crucial for the prevention and treatment of this treatment-resistant pain state. In the present study, associations between neuropathic pain characteristics and DNA methylation of the transient receptor potential ankyrin 1(TRPA1) gene were evaluated in chronic pain patients and preoperative patients. Methods: Pain and psychological states were prospectively assessed in patients who suffered chronic pain or were scheduled for thoracic surgery. Neuropathic characteristics were assessed using the Douleur Neuropathique 4 (DN4) questionnaire. DNA methylation levels of the CpG island in the TRPA1 gene were examined using whole blood. Results: Forty-eight adult patients were enrolled in this study. Increases in DNA methylation rates at CpG -51 showed positive correlations with increases in the DN4 score both in preoperative and chronic pain patients. Combined methylation rates at CpG -51 also significantly increased together with increase in DN4 scores. Conclusions: Neuropathic pain characteristics are likely associated with methylation rates at the promoter region of the TRPA1 gene in human peripheral blood.
ARTICLE | doi:10.20944/preprints201909.0330.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: myocardial injury after non-cardiac surgery; anesthetic technique; high-sensitivity troponin i
Online: 29 September 2019 (07:08:24 CEST)
The cardioprotective effects of volatile anesthetics versus total intravenous anesthesia (TIVA) are controversial, especially in patients undergoing non-cardiac surgery. Using current generation high-sensitivity cardiac troponin (hs-cTn), we aimed to evaluate the effect of anesthetics on the occurrence of myocardial injury after non-cardiac surgery (MINS). From February 2010 to December 2016, 3555 patients without preoperative hs-cTn elevation underwent non-cardiac surgery under general anesthesia. Patients were grouped according to anesthetic agent; 659 patients were classified into a propofol-remifentanil total intravenous anesthesia (TIVA) group, and 2896 patients were classified into into a volatile group. To balance the use of remifentanil between groups, a balanced group (n=1622) was generated with patients who received remifentanil infusion in the volatile group, and two separate comparisons were performed (TIVA vs. volatile and TIVA vs. balanced). The primary outcome was occurrence of MINS, defined as rise of hs-cTn I ≥ 0.04 ng/mL within postoperative 48 hours. The secondary outcomes were 30-day mortality, postoperative acute kidney injury (AKI), and adverse events during hospital stay (mortality, type I myocardial infarction (MI), and new-onset arrhythmia). In propensity-matched analyses, the occurrence of MINS was lower in the TIVA group compared to the volatile group (OR 0.642; 95% CI 0.450-0.914; p = 0.014). However, after balancing the use of remifentanil, there was no difference between groups in the risk of MINS (OR 0.832; 95% CI 0.554-1.251; p-value = 0.377). There were no significant associations between the two groups in type 1 MI, new-onset atrial fibrillation, in-hospital and 30-day mortality before and after balancing the use of remifentanil. However, the incidence of postoperative AKI was lower in the TIVA group (OR 0.362; 95% CI 0.194-0.675; p-value = 0.001). After balancing the use of remifentanil, volatile anesthesia and TIVA showed comparable effects on MINS in patients undergoing non-cardiac surgery without preoperative myocardial injury. Further studies are needed on the benefit of remifentanil infusion.
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: pharmacology; drug development; sodium channel; potassium channel; TRP channel; HCN channels
Online: 8 August 2019 (12:31:26 CEST)
Ion channels contribute fundamental properties to all cell membranes. The ion channels are highly diverse in conductivity, structure, location and function. However, many of them can be regulated by common mechanisms, such as voltage or (de-)phosphorylation. Considering primarily pain-related ion channels, this review covers more novel and less known features of ion channel function, also with the aim to transfer knowledge between fields, which get inevitably more separate due to their size.
ARTICLE | doi:10.20944/preprints201904.0030.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: Brody effect; electrocardiographic variation; R-wave amplitude; hemodynamic monitoring; pulse pressure variation
Online: 2 April 2019 (12:19:31 CEST)
The aim of this study was to analyze whether the respiratory variation in ECG standard lead II R-wave amplitude (ΔRDII) could be used to assess intravascular volume status following inferior vena cava (IVC) clamping. This clamping causes an acute decrease in cardiac output during liver transplantation (LT). We retrospectively compared ΔRDII and related variables before and after IVC clamping in 34 recipients. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were used to derive a cutoff value of ΔRDII for predicting pulse pressure variation (PPV). After IVC clamping, cardiac output significantly decreased while ΔRDII significantly increased (P = 0.002). The cutoff value of ΔRDII for predicting a PPV >13% was 16.9% (AUC: 0.685) with a sensitivity of 57.9% and specificity of 77.6% (95% confidence interval 0.561 – 0.793, P = 0.015). Frequency analysis of ECG also significantly increased in the respiratory frequency band (P = 0.016). Although significant changes in ΔRDII during vena cava clamping were found at norepinephrine doses < 0.1 μg/kg/min (P = 0.014), such changes were not significant at norepinephrine doses > 0.1 μg/kg/minP = 0.093). ΔRDII could be a noninvasive dynamic parameter in LT recipients presenting with hemodynamic fluctuation. Based on our data, we recommended cautious interpretation of ΔRDII may be requisite according to vasopressor administration status.
ARTICLE | doi:10.20944/preprints201811.0005.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: anaesthesia, general; anaesthesia recovery period; single dose of rocuronium; sugammadex; neostigmine
Online: 8 November 2018 (14:00:01 CET)
There is a lack of data comparing sugammadex with anticholinesterase for the quality of anaesthesia recovery, especially following a single bolus dose of rocuronium. Thus, we evaluated the influence of reversal with sugammadex or neostigmine on post-operative quality of recovery by using the Post-operative Quality Recovery Scale (PQRS). A total of 86 patients undergoing trans-pars plana vitrectomy (TPPV) under general anaesthesia were intubated following a single bolus dose of rocuronium (0.6 mg/kg). At the end of surgery, patients were received either neostigmine or sugammadex. The quality of recovery was assessed using the PQRS at 15 minutes and 40 minutes after surgery, and on post-operative day 1. The recovery rate in the physiological domain was higher in the sugammadex group at 15 minutes after surgery (P = 0.02). Though there were no significant differences in the overall cognitive recovery domain, patients in the sugammadex group could recall more numbers in reverse order. However, there were no significant differences between the groups in the other domains of the PQRS. The use of sugammadex may increase the quality of the post-operative physiological recovery at early post-operative periods compared with neostigmine use following a single bolus dose of rocuronium in patients undergoing TPPV with general anaesthesia.
REVIEW | doi:10.20944/preprints201806.0134.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: chronic pediatric pain; low income country; middle income country; low and middle income country; pediatric palliative care.
Online: 8 June 2018 (12:45:24 CEST)
Chronic pain is a serious health concern and potentially debilitating condition, leading to anxiety, depression, reduced productivity and functionality, and poor quality of life. This condition can be even more detrimental and incapacitating in the pediatric patient population. In low and middle income countries (LMICs), pain services are inadequate or unavailable, leaving most of the world's pediatric population with chronic pain untreated. Many of these children in LMICs are suffering without treatment, and often die in pain. Awareness and advocacy for this population must be prioritized. We reviewed the available literature on the chronic pediatric pain burden in LMICs, barriers to treatments, and current efforts to treat these patients.
ARTICLE | doi:10.20944/preprints201806.0083.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: anesthesia; neurotoxicity; synapse; mTOR; neurodevelopment
Online: 6 June 2018 (10:36:51 CEST)
Human epidemiologic studies and laboratory investigations in animal models suggest that exposure to general anesthetic agents (GAs) have harmful effects on brain development. The mechanism underlying this putative iatrogenic condition is not clear and there are currently no accepted strategies for prophylaxis or treatment. Recent evidence suggests that anesthetics might cause persistent deficits in synaptogenesis by disrupting key events in neurodevelopment. Using an in vitro model consisting of dissociated primary cultured mouse neurons we demonstrate abnormal pre- and post-synaptic marker expression after a clinically relevant isoflurane anesthesia exposure conducted during neuron development. We find that pharmacologic inhibition of the mechanistic target of rapamycin (mTOR) pathway can reverse the observed changes. Isoflurane exposure increases expression of phospho-S6, a marker of mTOR pathway activity, in a concentration-dependent fashion and this effect occurs throughout neuronal development. The mTOR 1 complex (mTORC1) and the mTOR 2 complex (mTORC2) branches of the pathway are both activated by isoflurane exposure and this is reversible with branch-specific inhibitors. Upregulation of mTOR is also seen with sevoflurane and propofol exposure, suggesting that this mechanism of developmental anesthetic neurotoxicity may occur with all the commonly used GAs in pediatric practice. We conclude that GAs disrupt the development of neurons during development by activating a well-defined neurodevelopmental disease pathway and that this phenotype can be reversed by pharmacologic inhibition.
ARTICLE | doi:10.20944/preprints201805.0364.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: ultrasonography; preoperative; postoperative; collabsibility index; inferior vena cava diameter
Online: 25 May 2018 (11:42:21 CEST)
Background: Ultrasound measurement of dynamic changes in inferior vena cava (IVC) diameter and collapsibility index (CI) evaluates to estimate the fluid responsiveness and intravascular volume status. We conducted a analysis to quantify the sonographic measurement of IVC diameter changes in adult patients at preoperative and postoperative period. Methods: Ultrasonography was performed on 72 patients scheduled for surgery with American Society of Anesthesiologists physical status I to III. Quantitative assessments of the end-expiration (Dmin), end-inspiration (Dmax) and CI at preoperative and postoperative period were compared in a prospective, observational study. The patients received intravenous fluid according to standard protocol regimes peroperatively. The cutt-off value of dIVC 40% was accepted as hypovolemia. Results: Ultrasonography of IVC measurement was unsuccessful in 12.5% of patients and 63 patients remained for analyses. The mean age was 43.29 ± 17.22 (range 18 - 86) years. The average diameter of the Dmin, Dmax and dIVC at preoperative and postoperative were 1.99 ± 0.31 vs. 2.05 ± 0.29 cm, 1.72 ± 0.33 vs. 1.74 ± 0.32 cm, 14.0 ± 9.60 % vs. 15.14 ± 11.18 %, respectively (p<0.05). Using a threshold dIVC of 40%, one patient preoperatively and 5 postoperatively were hypovolemic (p<0.05). CI was also positively associated preoperatively and postoperatively (regression coefficient = 0.438, p<0.01). Conclusion: The diameter of IVC did not change preoperatively and postoperatively in adult patients with standard fluid regimens. The parameters of the IVC diameter increased postoperatively according to preoperative period.
ARTICLE | doi:10.20944/preprints201804.0319.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: culture, ageing, pain, idioms of distress, somatisation, cultural concepts of distress, stoicism
Online: 24 April 2018 (17:13:05 CEST)
In this paper, the authors seek to discuss some of the complexities involved in cross-cultural working in relation to the communication and management of pain in older people. Specifically, the paper addresses the culture construction of ageing and how pain is often constructed as a natural part of ageing. The authors also suggests that with the rise of the ideology of active-ageing many older people who are disabled or living in chronic pain, may feel a moral imperative to hide pain and ill-health. The discussion extends into looking at the impact of culture and the communication of pain, including specific idioms of distress, somaticize and the lay-management of pain through stoicism.
REVIEW | doi:10.20944/preprints201712.0172.v1
Subject: Medicine And Pharmacology, Anesthesiology And Pain Medicine Keywords: palliative care team; seriously ill patients; end-of-life; quality of life; symptom relief; acute palliative care unit; cost savings
Online: 25 December 2017 (08:50:18 CET)
Traditionally, palliative care (PC) systems focused on the needs of advanced cancer patients. But, most patients needing PC have end-stage organ diseases. Similarly, PC models focused on the needs of patients in hospice or at home; however, in most cases PC is provided in acute hospitals. Indeed, the symptom burden that these patients experience in the last year of life frequently forces them to seek care in Emergency Department. The majority of them are admitted to the hospital and many die. This issue poses important concerns. Despite the efforts of attending healthcare professionals, inhospital patients do not receive optimal care near the end-of-life. Also, evidence is emerging that delay in identifying patients needing PC have a detrimental impact on their quality of life (QoL). Therefore, there is an urgent need to early and properly identify these patients among those hospitalized. Several trials reported the efficacy of PC in improving the QoL in these patients. Each hospital should ensure that a multidisciplinary PC team is available to support attending physicians to achieve the best QoL for both PC patients and their families. This review discusses the role and the impact of inhospital PC in patients with end-stage disease or advanced cancer.