Anesthesiologists Must Be Active in Patient Selection for Ambulatory Surgery

Surgeons may push anesthesia providers to participate in inappropriate or ill-fitting procedures at ambulatory surgery centers (ASCs), which is why it’s important to push back based on evidence-based practices to boost quality and positive outcomes.

“We should be the gatekeepers of patients coming to ASCs so we can be the gatekeepers of outcomes, too,” said Girish Joshi, MD, professor of anesthesiology and pain management at the University of Texas Southwestern Medical School, in Dallas, and past president of the Society for Ambulatory Anesthesia (SAMBA). Dr. Joshi spoke about patient selection in the ambulatory surgery setting at “Driving Change in Ambulatory Anesthesia,” a joint meeting held by SAMBA and the American Society of Anesthesiologists (ASA).

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Impact of an Electronic Pain and Opioid Risk Assessment Program

Are There Improvements in Patient Encounters and Clinic Notes?

The American Academy of Pain Medicine recently published an article by researchers at Inflexxion Inc., Newton-Wellesley Hospital’s Pain Management Center, Brigham and Women’s Hospital Pain Management Center, and at the University of Mississippi Medical Center, Family Medicine, that discusses the impact of PainCAS, a comprehensive electronic self-report pain and opioid risk assessment system, on clinical documentation and patient/provider communication.
Highlights from the study concluded that:

• Significant differences in favor of an electronic pain assessment condition were found
• Preliminary results indicate an electronic pain assessment program increases documentation of key elements of pain patient information in the medical record and improved discussion of substance abuse issues in the patient-physician encounter
• Standardization of assessments can lead to long-term improved quality of care

For more information about this study, please see the abstract.

Current Concepts In the Management of The Difficult Airway

 

Management of the difficult airway remains one of the most relevant and challenging tasks for anesthesia care providers. This review focuses on several of the alternative airway management devices/techniques and their clinical applications, with particular emphasis on the difficult or failed airway. It includes descriptions of many new airway devices, several of which have been included in the ASA Difficult Airway Algorithm.

A common factor preventing successful tracheal intubation is the inability to visualize the vocal cords during the performance of DL. Many devices and techniques are now available to circumvent the problems typically encountered with a difficult airway using conventional DL.

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Conclusion
Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment born of experience is crucial to their application. As with any intubation technique, practice and routine use will improve performance and may reduce the likelihood of complications. Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.

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Acupuncture Relieves Osteoporotic Spinal Fracture Pain

 

Acupuncture is effective for the treatment of osteoporotic compression fractures of the spine. Researchers tested the efficacy of a specialized form of acupuncture and found it effective for enhancing pain reduction for patients with spinal compression fractures due to osteoporosis.

Acupuncture combined with medications produced significantly greater positive patient outcomes including pain reduction and improvements in activities of daily living over medications only as a standalone therapy.

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5 Holistic Pain Relief Therapies for Palliative Care Patients

 

Palliative care is care that provides pain relief, and is used with curative measures, but does not act towards a cure on its own. In other words, it helps make patients more comfortable as they struggle against serious illnesses.

Best practice in medicine suggests that patients undergoing palliative care benefit most from a holistic approach. Holistic approaches include physical, psychological, and spiritual comfort.
As a result, therapies that help patients can be provided not only by doctors and nurses but also by counselors, therapists, massage therapists, or even family and friends of the patient. These actors can provide complementary pain relief therapies, which are able to help reduce pain and improve quality of life, and support the patient as a whole.

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Multimodal Analgesic Protocol Improves Analgesia, Pain Documentation After Arthroplasty

 

The implementation of a multimodal analgesic protocol may be a simple, effective way to boost the documentation of preoperative pain scores and opioid use in an acute pain service, new research suggests.

Multimodal protocols for nonopioid analgesia using acetaminophen, cyclooxygenase-2 inhibitors, gabapentinoids and peripheral nerve catheters have been shown to decrease opioid use and improve patient analgesia, according to researchers from the University of Florida, in Jacksonville. However, the effect of these protocols on baseline assessment of patient pain and opioid use, which is “key to providing an appropriate level of postoperative analgesia,” has not been investigated, they wrote.

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Anesthesiology News

Percutaneous Electrical Neurostimulation for Detoxification in Opioid-Dependent Chronic Pain Patients

Percutaneous Electrical Neurostimulation for Detoxification in Opioid-Depend reduction in opioid-dependent patients (detoxification) always has been challenging. However, when the scenario also includes a chronic, severe pain problem, as either an initiating or underlying cause of that dependence, the process can be significantly more difficult.

Practical pain management_-_Percutaneous_Electrical_Neurostimulation_for_detoxification_in_opioid-dependent_chronic_pain_patients_-_2015-10-21 from MaxiMedRx

Combination Dexamethasone Reduces Pain, Enhances Nerve Block Duration Compared With Systemic Dex Alone

 

The combination of systemic and perineural dexamethasone improved pain scores and decreased opioid requirements after compared with systemic dexamethasone alone, a new study shows. According to the data, when combined with systemic dexamethasone (8 mg), perineural dexamethasone (4 mg) also improved pulmonary function in patients postoperatively compared with control.

“When bupivacaine is administered as an intercostal nerve block in the presence of systemic dexamethasone, patients are probably getting around 20 hours of pain relief,” said Dermot P. Maher, MD, MS, pain medicine fellow at Massachusetts General Hospital and Harvard Medical School, in Boston. “But if you add [perineural] dexamethasone to that mixture, they get around 24 to 28 hours of relief...

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Acupuncture Alleviates Migraines

 

Acupuncture and cupping are effective for migraine relief. Tianjin University of Traditional Chinese Medicine researchers tested two acupuncture protocols. One of the acupuncture protocols achieved a 100% total effective rate with an 88.6% complete recovery rate. This involved a combination of acupuncture and cupping. Another protocol, using only acupuncture, achieved a 94.3% total effective rate with a 62% complete recovery rate. The superior positive patient outcomes achieved in the acupuncture plus cupping protocol were achieved using a set of specialized acupuncture points.

Migraines are headaches of moderate to severe intensity that are unilateral or throbbing. Attacks range from several hours to several days per migraine. Nausea, vomiting, sensitivity to sound and light, auras, flashes of light, and blind spots are often concomitant. According to the Mayo Clinic staff, “Clinical trials have found that acupuncture may be helpful for headache pain.”

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Can treatment success with 5% lidocaine medicated plaster be predicted in cancer pain with neuropathic components or trigeminal neuropathic pain?

 

An expert group of 40 pain specialists from 16 countries performed a first assessment of the value of predictors for treatment success with 5% lidocaine-medicated plaster in the management of cancer pain with neuropathic components and trigeminal neuropathic pain. Results were based on the retrospective analysis of 68 case reports (sent in by participants in the 4 weeks prior to the conference) and the practical experience of the experts. Lidocaine plaster treatment was mostly successful for surgery or chemotherapy-related cancer pain with neuropathic components.

A dose reduction of systemic pain treatment was observed in at least 50% of all cancer pain patients using the plaster as adjunct treatment; the presence of allodynia, hyperalgesia or pain quality provided a potential but not definitively clear indication of treatment success. In trigeminal neuropathic pain, continuous pain, severe allodynia, hyperalgesia, or postherpetic neuralgia or trauma as the cause of orofacial neuropathic pain were perceived as potential predictors of treatment success with lidocaine plaster. In conclusion, these findings provide a first assessment of the likelihood of treatment benefits with 5% lidocaine-medicated plaster in the management of cancer pain with neuropathic components and trigeminal neuropathic pain and support conducting large, well-designed multicenter studies.

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Acupuncture Relieves Post-Stroke Anxiety & Depression

 

Acupuncture relieves anxiety and depression experienced by stroke patients. Researchers from the Shanghai University of TCM (Traditional Chinese Medicine) investigated the efficacy of acupuncture and medications for the treatment of post-stroke anxiety and depression. The SSRI (serotonin reuptake inhibitor drug sertraline demonstrated a 73.3% total efficacy rate. Conventional acupuncture achieved an 80% total effective rate. Another group received a treatment protocol of Sun Si-Miao’s ghost acupoints combined with sertraline. The combination group achieved a 93.3% total effective rate. The researchers concluded that the combination of acupuncture with drug therapy is safe and effective for the treatment of anxiety and depression due to post-stroke syndrome.

Sertraline is an antidepressant used for the treatment of depression, panic attacks, anxiety, and obsessive-compulsive disorder. Common side effects include drowsiness, dizziness, nausea, insomnia, decreased libido, inability to have an orgasm, constipation, and stomach pain. The group receiving sertraline received dosages ranging between 25 and 75 mg/day based on the condition and severity of side effects.

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Palliative Care Sometimes Adds To Families’ Stress Burden

Palliative-care counseling from trained specialists is not routinely needed for all families of patients with chronic critical illnesses and sometimes it might worsen their emotional distress, cautions a recent study.

 Habitually providing scarce palliative care services to cases indiscriminately may be ineffective when the meetings are limited to just one or two sessions, reported researchers in the July 5 issue of JAMA.

 Family caregivers were no less depressed or anxious when they received only routine counseling from staff members in intensive care units, researchers found. With further support and training, ICU teams could deliver primary palliative care for surrogate decision makers of some patients, they suggested.

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Reduced Cancer Risk, Improved Survival With Neuraxial Anesthesia

 

Neuraxial anesthesia (NA) appears to be associated with improved overall survival (OS) in patients undergoing surgery for tumor resection, particularly in those with colorectal cancer. According to a recent meta-analysis published in Oncotarget (2016;7:15262-15273), the authors identified a correlation between the use of NA and reduced risk for cancer recurrence.

 The authors found significantly improved OS and reduced cancer recurrence with NA versus general anesthesia (GA). This finding is among those that show that anesthetic technique correlates with clinically important outcomes, including mortality and morbidity. “Specifically, we found a positive association between neuraxial anesthesia and improved OS in colorectal cancer (HR [hazard ratio] 0.653; 95% CI 0.430-0.991, P=0.045, the random-effects model),” they explained.

 “Our results suggest that … the use of [NA] has been found to be associated with improved OS after colorectal cancer, prostate cancer, gastro-oesophageal cancer, laryngeal and hypopharyngeal cancer, and ovarian cancer surgery,” the researchers wrote.

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ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy

 

New Orleans—With surgery still the primary treatment for breast cancer, strategies to minimize acute postoperative pain have the potential for signific
ant benefit, perhaps even preventing development of chronic pain. A research team at the University of California, San Francisco (UCSF) has moved much closer to this lofty goal. They developed an enhanced recovery after surgery (ERAS) pathway that significantly decreased opioid consumption, acute postoperative pain, and postoperative nausea and vomiting (PONV) in women undergoing total mastectomy.

 “There’s a movement in anesthesia to improve patient care by implementing ERAS pathways,” said Monica Harbell, MD, assistant clinical professor of anesthesia and perioperative care at UCSF’s School of Medicine. “Nevertheless, there haven't been many enhanced recovery pathways in breast surgery. So we wanted to apply the principles of enhanced recovery in an effort to get our patients mobilized earlier, more active and involved in their care, and hopefully achieve better outcomes and greater patient satisfaction.”

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