Effects of Multimodal Analgesia on Recovery From Percutaneous Spinal Cord Stimulator Implantation.

OBJECTIVE: We aimed to determine the relationship between number and type of analgesic modalities utilized and postoperative pain after percutaneous spinal cord stimulator implantation. Secondary measures include opioid requirements, discharge times, and effects of specific modalities. MATERIALS AND METHODS: This single-center retrospective cohort at Brooke Army Medical Center from April 2008 through July 2017 reviewed 70 patients undergoing stimulator implantation by a pain specialist. Data included: home opioid regimen; preoperative/postoperative medications and pain; intraoperative medications; and discharge times. Analysis utilized a Wilcoxon nonparametric mode, and chi-square testing for specific modalities. We compared outcomes based on the number of modalities administered and whether patients received specific medications. RESULTS: Patients averaged receiving 3.8 modalities (standard deviation 1.4). Patients receiving ≥5 modalities had increased pain from preoperative to postoperative scores by two points, while those who received ≤4 had no increase (p < 0.01). Patients receiving ketamine had a median three point increase in pain scores from their baseline vs no change for others (p < 0.05). Patients receiving four modalities had shorter phase one recovery times vs ≤ 2 (median 66 vs 91.5 min; p = 0.01). Patients receiving ≥4 modalities had shorter times vs ≤3 (median 74 vs 88.5 min; p < 0.01). Patients receiving NSAIDs had shorter times than others (median 78 vs 87 min; p < 0.05). CONCLUSIONS: Ketamine administration and use of ≥5 analgesic modalities were associated with more postoperative pain for unclear reasons. Patients receiving NSAIDs or ≥4 analgesic modalities had shorter recovery times. These data may lead to further work that could optimize ambulatory practices for stimulator implantation. More work is warranted on this subject.

Regional Anesthesia Facilitating Surgical and Medical Management of a Patient with Necrotizing Fasciitis and Diabetic Ketoacidosis.

Emergent surgery in the setting of a concomitant medical (nonsurgical) emergency challenges the anesthesiology team with multiple and often conflicting concerns. During these rare situations, general anesthesia is often employed. This case report demonstrates a safe and effective regional anesthetic technique utilized as the primary anesthetic during emergent surgery in the setting of a medical emergency. In this particular case, the medical emergency was profound diabetic ketoacidosis and the surgical emergency was life-threatening necrotizing fasciitis of the left upper extremity. An ever-increasing body of literature supports that anesthetic technique has an impact on morbidity and mortality outcomes in specific patient populations. The aim of this case report is to describe the successful use of regional anesthesia to facilitate emergent surgery in a patient who also has a concurrent emergent medical condition. In addition, we review the literature describing the utility of regional anesthesia in such patients.

Regional Anesthesia in the Combat Setting: Are ACGME Requirements Enough?

INTRODUCTION: Updated Joint Trauma System Clinical Practice Guidelines (CPG) indicate regional anesthesia and pain management (RAAPM) are important for combat casualty care. However, it is unclear whether military anesthesiology residents are receiving adequate RAAPM training to meet the CPGs. The goal of this study was to conduct a preliminary evaluation of resident-completed combat-relevant regional anesthesia procedures. It was hypothesized that most residents would perform an adequate number of each procedure to presume proficiency. MATERIALS AND METHODS: Resident-performed, combat-relevant regional anesthesia procedure frequency was extracted from a database maintained at a military anesthesiology residency program. Data collection was limited to a 1-year period. Univariate statistics described procedure distributions, frequencies, and proportion of residents achieving pre-defined, empirically-supported experience criteria for each technique. Analyses examined proportional differences in meeting experience criteria by training-year. RESULTS: Residents (N = 41) performed a variety of procedures. Simple procedures, such as saphenous peripheral nerve blocks, were performed at a greater frequency than more complicated procedures such as thoracic epidurals, continuous peripheral nerve blocks, and transverse abdominus plane blocks. The majority of residents met experience criteria for four out of the eight measured combat-relevant blocks. There were no proportional differences in meeting procedural experience criteria across the different training levels. CONCLUSIONS: These results suggest a possible gap between the needs of the Military Health System during conflict and current residency training experiences. Reasons for this gap, as well as solutions, are explored.

Military Service Members and Emergence Delirium Screening: An Evidence-Based Practice Project.

PURPOSE: Emergence delirium (ED) is a postoperative phenomenon characterized by agitation, confusion, and violent physical or verbal behavior that can occur after general anesthesia. Preoperative identification of patients at risk for ED may allow providers to take steps to minimize the incidence or severity of ED. Because no formal tool currently exists, the purpose of this project was to develop and evaluate a screening tool based on available evidence of ED risk factors. DESIGN: This quality improvement project used a preimplementation and postimplementation design. METHODS: One hundred consecutive adult patient charts were reviewed 2 months before implementation of the project questionnaire. These data were used to confirm preimplementation screening rates. Postimplementation, prospective data were gathered to test this newly developed assessment tool for usefulness in the clinical setting. FINDINGS: The use of this focused screening tool significantly increased preoperative identification of patients at risk for ED compared with the preimplementation preoperative screening routine. Identification rates for at-risk patients rose from 5% to 21%-22.5% using this tool. CONCLUSIONS: This project demonstrated that the use of a focused tool to identify risk factors for ED could significantly increase actual identification rates for at-risk patients in the clinical setting.

Clinical agreement in the American Society of Anesthesiologists physical status classification.

BACKGROUND: The American Society of Anesthesiologists physical status (ASA-PS) classification is not intended to predict risk, but increasing ASA-PS class has been associated with increased perioperative mortality. The ASA-PS class is being used by many institutions to identify patients that may require further workup or exams preoperatively. Studies regarding the ASA-PS classification system show significant variability in class assignment by anesthesiologists as well as providers of different specialties when provided with short clinical scenarios. Discrepancies in the ASA-PS accuracy have the potential to lead to unnecessary testing and cancelation of surgical procedures. Our study aimed to determine whether these differences in ASA-PS classification were present when actual patients were evaluated rather than previously published scenario-based studies. METHODS: A retrospective chart review was completed for patients >/= 65 years of age undergoing elective total hip or total knee replacements. One hundred seventy-seven records were reviewed of which 101 records had the necessary data. The outcome measures noted were the ASA-PS classification assigned by the internal medicine clinic provider, the ASA-PS classification assigned by the Pre-Anesthesia Unit (PAU) clinic provider, and the ASA-PS classification assigned on the day of surgery (DOS) by the anesthesia provider conducting the anesthetic care. RESULTS: A statistically significant difference was shown between the internal medicine and the PAU preoperative ASA-PS designation as well as between the internal medicine and DOS designation (McNemar p = 0.034 and p = 0.025). Low kappa values were obtained confirming the inter-observer variation in the application of the ASA-PS classification of patients by providers of different specialties [Kappa of 0.170 (- 0.001, 0.340) and 0.156 (- 0.015, 0.327)]. CONCLUSIONS: There was disagreement in the ASA-PS class designation between two providers of different specialties when evaluating the same patients with access to full medical records. When the anesthesia-run PAU and the anesthesia assigned DOS ASA-PS class designations were evaluated, there was agreement. This agreement was seen between anesthesia providers regardless of education or training level. The difference in the application of the ASA-PS classification in our study appeared to be reflective of department membership and not reflective of the individual provider's level of training.

Dexmedetomidine as a Rescue Therapy for Emergence Delirium in Adults: A Case Series.

Emergence delirium (ED) in adult patients encountered in the postanesthesia care unit (PACU) is not well studied; nor are ED treatment strategies. Similar to delirium in the intensive care unit, ED in the PACU can result in serious complications. We describe 3 cases of ED in the PACU in patients with a history of posttraumatic stress disorder who were successfully treated with dexmedetomidine. Although likely utilized more frequently in recent years, the use of dexmedetomidine in the PACU for treatment of ED is not established in the literature. Further research regarding treatment of ED in adults is necessary, allowing for optimization of patient care and improvement in patient outcomes.

Anesthetic management of an ex utero intrapartum treatment procedure: a novel balanced approach.

Ex utero intrapartum treatment (EXIT) procedures are therapeutic interventions for fetuses with life-threatening airway abnormalities and/or other prenatally diagnosed congenital malformations requiring immediate neonatal extracorporeal membrane oxygenation support. Although certain anesthetic goals are common among EXIT procedures, many different approaches to their management have been described in the literature. Herein, we present a novel anesthetic approach to an EXIT procedure for fetal micrognathia and retrognathia. We also review the indications and anesthetic considerations for these procedures and highlight the need for multidisciplinary collaboration to optimize clinical outcomes.

Progress of clinical practice on the management of burn-associated pain: Lessons from animal models.

Opioid-based analgesics provide the mainstay for attenuating burn pain, but they have a myriad of side effects including respiratory depression, nausea, impaired gastrointestinal motility, sedation, dependence, physiologic tolerance, and opioid-induced hyperalgesia. To test and develop novel analgesics, validated burn-relevant animal models of pain are indispensable. Herein we review such animal models, which are mostly limited to rodent models of burn-induced, inflammatory, and neuropathic pain. The latter two are pain syndromes that provide insight into the pain caused by systemic pro-inflammatory cytokines and direct injury to nerves (e.g., after severe burn), respectively. To date, no single animal model optimally mimics the complex pathophysiology and pain that a human burn patient experiences. No currently available burn-pain model examines effects of pharmacological intervention on wound healing. As cornerstones of pain and wound healing, pro-inflammatory mediators may be utilized for insight into both processes. Moreover, common clinical concerns such as systemic inflammatory response syndrome and multiple organ dysfunction remain unaddressed. For development of analgesics, these aberrations can significantly alter the potential efficacy and/or adverse effects of a prescribed analgesic following burn trauma. We therefore suggest that a multi-model strategy would be the most clinically relevant when evaluating novel analgesics for use in burn patients.

The intraoperative administration of ketamine to burned U.S. service members does not increase the incidence of post-traumatic stress disorder.

AIM: Patients with severe burns typically undergo multiple surgeries, and ketamine is often used as part of the multimodal anesthetic regimen during such surgeries. The anesthetic ketamine is an N-methyl-D-aspartate receptor antagonist that also provides analgesia at subanesthetic doses, but the psychoactive side effects of ketamine have caused concern about its potential psychological effects on a combat-wounded population. Post-traumatic stress disorder (PTSD) affects approximately 30% of burned U.S. service members injured in Operation Iraqi Freedom/Operation Enduring Freedom. A preliminary analysis by our research group reported that patients who received perioperative ketamine had a significantly lower prevalence of PTSD than those injured service members who did not receive ketamine. We have now expanded this research to examine the relationship between ketamine and PTSD development in a much larger population. METHODS: A retrospective analysis on data from service members being treated for burns at the San Antonio Military Medical Center was conducted. Collected data included drugs received, injury severity score (ISS), total body surface area (TBSA) burned, length of hospital stay (LOS), number of intensive care unit days, number of surgeries, and PTSD Checklist-Military (PCL-M) scores and administration dates. Subjects were grouped based on intraoperative receipt of ketamine, and the groups were compared. The groups were binary for ketamine (yes or no), and dose of ketamine administered was not included in data analyses. Propensity score matching based on ISS and TBSA was performed to control for individual differences in burn severity. RESULTS: Two hundred eighty-nine burned U.S. service members received the PCL-M at least 30 days after injury. Of these subjects, 189 received intraoperative ketamine, and 100 did not. Despite significantly greater injuries, as evidenced by significantly higher TBSA burned and ISS (p < 0.01), patients who received ketamine did not screen positive for PTSD at a different rate than those patients who did not (24% vs. 26.98%, p = 0.582). Patients receiving intraoperative ketamine also underwent a significantly greater number of surgeries, spent more time in the hospital, spent more days in the ICU, and received more morphine equivalent units (p < 0.0001). Propensity score matching based on ISS and TBSA resulted in a total subject number of 130. In the matched samples, subjects who received ketamine still underwent significantly more surgeries and experienced longer hospital stays (p < 0.0001). Again, there was no statistically significant difference in the incidence of a positive screen for PTSD based upon the receipt of ketamine (28% vs. 26.15%, p = 0.843). CONCLUSIONS: Ketamine is often used in burn patients to reduce opioid usage and decrease the hemodynamic and respiratory side effects. Although this study does not show a benefit of ketamine on PTSD development that was identified in previous work with a smaller sample number, it does support the conclusion that ketamine does not increase PTSD development in burned service members.

Use of the LMA Supreme in the Special Operations Environment: A Retrospective Comparison of the LMA Supreme and King LT-D.

The purpose of this study is to evaluate the use of the LMA Supreme® (LAM) as a combat supraglottic airway for U.S. Special Operations Forces (SOF). It is imperative to continuously evaluate and compare existing management options for airway control as requirements and technologies change. Providing our Special Operators with the most advanced and reliable medical equipment is of the utmost importance, and it is our intention here to compare the LMA Supreme with the currently fielded King LT-D® (King Systems) to determine whether the LMA Supreme may be a viable alternative supraglottic airway.

Risk factors for hypotension in urgently intubated burn patients.

BACKGROUND: When urgently intubating patient in the burn intensive care unit (BICU), various induction agents, including propofol, are utilized that may induce hemodynamic instability. METHODS: A retrospective review was performed of consecutive critically ill burn patients who underwent urgent endotracheal intubation in BICU. Basic burn-related demographic data, indication for intubation, and induction agents utilized were recorded. The primary outcomes of interest were clinically significant hypotension requiring immediate fluid resuscitation, initiation or escalation of vasopressors immediately after intubation. Secondary outcomes included ventilator days, stay length, and in-hospital mortality. RESULTS: Between January 2003 and August 2010, we identified 279 urgent intubations in 204 patients. Of these, the criteria for presumed sepsis were met in 60% (n=168) of the intubations. After intubation, 117 patients (42%) experienced clinically significant hypotension. Propofol (51%) was the most commonly utilized induction agent followed by etomidate (23%), ketamine (15%), and midazolam (11%). On multiple logistic regression, %TBSA (OR 1.016, 95% CI 1.004-1.027, p<0.001) and presumed sepsis (OR 1.852, 95% CI 1.100-3.117, p=0.02) were the only significant predictors of hypotension. None of the induction agents, including propofol, were significantly associated with hypotension in patients with or without presumed sepsis. CONCLUSIONS: In critically ill burn patients undergoing urgent endotracheal intubation, specific induction agents, including propofol, were not associated with clinically significant hypotension. Presumed sepsis and %TBSA were the most important risk factors.

Translational advances in pain and anesthesia for cancer patients.

Effective cancer pain management requires multidisciplinary approaches for multimodal analgesia. Although opioids have been the cornerstone, developments such as regional anesthesia and interventional pain techniques, complementary and alternative medicine, and new pharmaceuticals also have shown promise to relieve cancer pain. This overview of relevant clinical efforts and the modern day state of the science will afford a better understanding of pain mechanisms and multimodal approaches beneficial in optimizing analgesia for cancer patients.

The relationship between gabapentin and pregabalin and posttraumatic stress disorder in burned servicemembers.

Posttraumatic stress disorder (PTSD) affects approximately 30% of burned Servicemembers returning from Operation Iraqi Freedom/Operation Enduring Freedom. Gabapentin and pregabalin are anticonvulsant drugs that limited evidence suggests may also be effective treatments for some psychological disorders. This study examines the relationship between these anticonvulsants and PTSD development in burned Servicemembers. Drugs received, injury severity score, TBSA burned, length of hospital stay, number of intensive care unit days, number of surgeries, and PTSD Checklist-Military scores and administration dates were collected. Subjects were grouped based on receipt of gabapentin or pregabalin, and the groups were compared. The primary outcome was incidence of a positive screen for PTSD. Because injury severity was significantly different between the two groups, propensity score matching based on injury severity score and TBSA was performed. Two hundred ninety burned Servicemembers received the PTSD Checklist-Military at least 30 days after injury. Of these subjects, 104 received gabapentin, pregabalin, or both and 186 did not. Despite significantly greater injuries, the group that received gabapentin or pregabalin did not develop PTSD at a different rate than those patients who did (P = .727). Propensity score matching resulted in 57 patients in each group; there was no difference between these groups in the incidence of PTSD (P = .663). These data suggest that gabapentin or pregabalin administration may not affect PTSD development in burned Servicemembers. Many factors influence the development and progression of PTSD, but few drugs have been identified that are effective at treating or preventing PTSD.

Use of ultra rapid opioid detoxification in the treatment of US military burn casualties.

BACKGROUND: The purpose of this case series was to review the management of burn patients who requested ultrarapid opioid detoxification under anesthesia after extended duration of narcotic use for chronic pain related to burn injury. METHODS: The treatment plan of six opioid-dependent burn patients was analyzed to assess the effectiveness of our detoxification practice to date. Demographic and clinical information was used to characterize the patient population served: age, burn size, injury severity, duration of narcotic use before detoxification intervention, and length of hospitalization stay. Daily narcotic consumption, in morphine equivalent units, was noted both before and after detoxification. RESULTS: Six burn patients (average age, 31 years) underwent detoxification at the Burn Center during a hospitalization lasting between 1 day and 2 days. Average burn size was 38% total body surface area (range, 17-65); average Injury Severity Score was 30 (range, 25-38). Mean duration of narcotic use was 672 days (range, 239-1,156 days); average use of narcotics at time of detoxification was >200 units daily. Mean outpatient consumption for opioids after the intervention was minimal (<25 units/d). No complications were noted during any procedures. CONCLUSIONS: The results of ultrarapid opioid detoxification under anesthesia suggests that it is safe and effective for treating opioid addiction in military burn casualties when a coordinated, multidisciplinary approach is used. Safety and effectiveness to date validate current practice and supports incorporation into clinical practice guidelines. Further clinical research is warranted to identify those patients who may benefit most from detoxification and to determine the timing of such treatment.

Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles.

BACKGROUND: This is the first controlled study to explore whether adjunctive immersive virtual reality (VR) can reduce excessive pain of soldiers with combat-related burn injuries during wound debridement. METHODS: Patients were US soldiers burned in combat attacks involving explosive devices in Iraq or Afghanistan. During the same wound care session using a within-subject experimental design, 12 patients received half of their severe burn wound cleaning procedure (~6 minutes) with standard of care pharmacologies and half while in VR (treatment order randomized). Three 0 to 10 Graphic Rating Scale pain scores for each of the treatment conditions served as the primary variables. RESULTS: Patients reported significantly less pain when distracted with VR. "Worst pain" (pain intensity) dropped from 6.25 of 10 to 4.50 of 10. "Pain unpleasantness" ratings dropped from "moderate" (6.25 of 10) to "mild" (2.83 of 10). "Time spent thinking about pain" dropped from 76% during no VR to 22% during VR. Patients rated "no VR" as "no fun at all" (<1 of 10) and rated VR as "pretty fun" (7.5 of 10). Follow-up analyses showed VR was especially effective for the six patients who scored 7 of 10 or higher (severe to excruciating) on the "worst pain" (pain intensity) ratings. CONCLUSIONS: These preliminary results provide the first evidence from a controlled study that adjunctive immersive VR reduced pain of patients with combat-related burn injuries during severe burn wound debridement. Pain reduction during VR was greatest in patients with the highest pain during no VR. These patients were the first to use a unique custom robot-like arm mounted VR goggle system.

Relationships between early acute pain scores, autonomic nervous system function, and injury severity in wounded soldiers.

BACKGROUND: Acute pain after injury affects the comfort and function of the wounded soldier and the physiology of multiple body systems. In the civilian population, pain alters the function of the autonomic nervous system, causing increased heart rate and blood pressure. However, there are no data regarding the impact of combat-related pain on physiologic responses. This study is a retrospective analysis that examined the relationship of pain and physiologic parameters in injured soldiers. METHODS: After Institutional Review Board approval, the Joint Trauma Theater Registry (JTTR) was queried to identify soldiers who had pain scores recorded in the Emergency Department (ED) in theater. Subject data collected from the JTTR included the following: pain score, Injury Severity Score (ISS), blood pressure, heart rate, and respiratory rate. RESULTS: We identified 2,646 soldiers with pain scores recorded in the ED. The pain score was not related to most physiologic parameters measured in the ED. Pain intensity had no correlation with blood pressure or heart rate. However, there were relationships between the pain score and respiratory rate, with patients reporting a pain score of 10 having a slightly higher respiratory rate. Increasing pain scores were also associated with increased ISS (p < 0.001). CONCLUSIONS: In contrast to data from civilian patients, early pain scores were not related to heart rate or blood pressure. A pain score of 10 corresponded to an increased respiratory rate. Despite little relationship between pain and injury severity in the civilian population, the increasing ISS was proportional to the pain scale in wounded soldiers.

Combining ketamine and virtual reality pain control during severe burn wound care: one military and one civilian patient.

BACKGROUND: US soldiers injured in Iraq, and civilian burn trauma patients are treated at the US Army Institute of Surgical Research. Burn patients experience extreme pain during wound care, and they typically receive opioid analgesics and anxiolytics for debridement. Virtual Reality (VR) has been applied as an adjunct to opioid analgesics for procedural pain. We describe the first use of ketamine combined with immersive VR to reduce excessive pain during wound care. CASE REPORT: A 21-year-old male US Army soldier stationed in Iraq, and a 41-year-old civilian male sustained a 13% and 50% total body surface area (TBSA) burn, respectively. Each patient received 40 mg ketamine intraveneous (IV) for wound care. Using a within-subject design, nurses conducted half of a painful segment of wound care treatments with no VR and the other half with immersive VR. Graphic pain rating scores for each of the two treatment conditions served as the dependent variables. RESULTS: Compared to ketamine + no VR, both patients reported less pain during ketamine + VR for all three pain ratings. Both patients rated wound care during no VR as "no fun at all", but those same patients rated wound care during virtual reality as either "pretty fun" or "extremely fun", and rated nausea as either "mild" or "none". CONCLUSIONS: Results from these first two cases suggest that a moderate dose of ketamine combined with immersive virtual reality distraction may be an effective multimodal analgesic regimen for reducing acute procedural pain during severe burn wound cleaning.

The relationship of early pain scores and posttraumatic stress disorder in burned soldiers.

Early acute pain after injury has been linked to long-term patient outcomes, including the development of posttraumatic stress disorder (PTSD). Several studies have identified a negative correlation between early anesthetic/analgesic usage and subsequent development of PTSD. This retrospective study examined the relationship between early acute pain and severity of PTSD symptoms in soldiers with burn injuries. Of the soldiers injured in Overseas Contingency Operations who had pain scores recorded at admission to the Emergency Department, 113 had burn injuries. Of those transferred to the military burn center, 47 were screened for PTSD using the PTSD checklist-military (PCL-M) survey at least 1 month after injury. Soldiers with mild, moderate, and severe pain scores had similar Injury Severity Scores and TBSA burned (P = .339 and .570, respectively). However, there were significant differences in PCL-M scores between the mild and severe pain groups (P = .017). The pain levels positively correlated with the PCL-M score (rho = 0.41, P = .004) but not with injury severity markers (Injury Severity Score and TBSA). These data suggest that early acute pain may be related to increased PCL-M score and PTSD symptoms. The intensity of pain was not related to the injury severity, and these data also show no association between pain intensity and physiological measures, including blood pressure and heart rate. However, this is a small sample size, and many other factors likely influence PTSD development. Further study is necessary to explore the relationship between early acute pain and subsequent development of PTSD symptoms.