Perceived barriers to a career in pain medicine in the Republic of Ireland.

BACKGROUND: As the population ages, musculoskeletal disorders are a prominent contributory factor to loss of mobility and autonomy. Pain is a predictor of disability and worsening frailty and the role of the chronic pain specialist in the management of this cohort cannot be overstated. With growing requirements for pain specialists, we sought to identify barriers to recruitment within this specialty. AIMS: Establish baseline attitudes and perceived barriers towards a career in pain medicine among Irish anaesthesiology trainees. Suggest a framework to improve recruitment to the specialty. METHODS: Ethical approval was obtained. A web-based questionnaire was sent to all anaesthesiologists in training in the Republic of Ireland. Data was analyzed using SPSS. RESULTS: Two hundred forty-eight trainees received the questionnaire, 59 responded. 54.2% male, 45.8% female. 79.7% had previous clinical exposure to pain medicine, most of whom had spent over one month with a service. Only 10.2% of respondents were considering a career in pain medicine. Factors that attracted trainees to the subspeciality included: interventional practice (81%), variation in clinical practice (66.7%), autonomy of practice (61.9%) and perceived good work-life balance (42.9%). Deterrents from the subspecialty included a psychologically challenging patient cohort (69.5%), frequency of clinics (50.8%), and additional exams (32.2%). When asked how to improve engagement with the speciality, 62% suggested earlier exposure to the speciality and 32.2% suggested increased frequency of formal teaching and workshops. CONCLUSIONS: Increased exposure of trainees to the specialty during early stages of training may improve future recruitment to the subspecialty in Ireland.

Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery-comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial.

BACKGROUND: Minimally invasive thoracic surgery (MITS) has been shown to reduce postoperative pain and contribute to better postoperative quality of life as compared to open thoracic surgery (Bendixen et al., Lancet Oncol 17:836-44, 2016). However, it still causes significant post-operative pain. Regional anaesthesia techniques including fascial plane blocks such as the erector spinae plane block (ESP) have been shown to contribute to post-operative pain control after MITS (Finnerty et al., Br J Anaesth 125:802-10, 2020). Case reports relating to ESP catheters have described improved quality of pain relief using programmed intermittent boluses (PIB) instead of continuous infusion (Bendixen et al., Lancet Oncol 17:836-44, 2016). It is suggested that larger, repeated bolus dose may provide superior pain relief, possibly because of improved spread of the local anaesthetic medications (Ilfeld and Gabriel, Reg Anesth Pain Med 44:285-86, 2019). Evidence for improved spread of local anaesthetic may be found in one study which demonstrated that PIB increased the spread of local anaesthetic medication compared to continuous infusions for continuous paravertebral blocks, which are another type of regional anaesthesia technique for the chest wall (Hida et al., Reg Anesth Pain Med 44:326-32, 2019). Similarly, regarding labour epidural analgesia, the weight of evidence is in favour of PIB providing better pain relief compared with continuous infusion (Onuoha, Anesthesiol Clin 35:1-14, 2017). Since fascial plane blocks, such as ESP, rely on the spread of local anaesthetic medication between muscle layers of the chest wall, intermittent boluses may be particularly useful for this group of blocks. However, until recently, pumps capable of providing automated boluses in addition to patient-controlled boluses were not widely available. To best of our knowledge, there are no randomised controlled trials comparing continuous infusion versus intermittent bolus strategies for erector spinae plane block for MITS in terms of patient centred outcomes such as quality of recovery. METHODS: This trial will be a prospective, double-blinded, randomised controlled superiority trial. A total of 60 eligible patients will be randomly assigned to receive an intermittent bolus regime of local anaesthetic vs a continuous infusion of local anaesthetic. The medication will be delivered via an ultrasound-guided erector spinae plane block catheter which will be inserted by an anaesthesiologist while the patient is under general anaesthetic before their MITS surgery begins. The primary outcome being measured is the Quality of Recovery (QoR-15) score between the two groups 24 h after surgery. Secondary outcomes include respiratory testing of maximal inspiratory volume measured with a calibrated incentive spirometer, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 score at 48 h and time to first mobilisation. DISCUSSION: Despite surgical advancements in thoracic surgery, severe acute post-operative pain following MITS is still prevalent. This study will provide new knowledge and possible recommendations about the efficacy of programmed intermittent bolus regimen of local anaesthetic vs a continuous infusion of local anaesthetic via an ultrasound-guided erector spinae plane catheter for patients undergoing MITS. TRIAL REGISTRATION: This trial was pre-registered on ClinicalTrials.gov Identifier: NCT05181371 . Registered on 6 January 2022. All item from the World Health Organization Trial Registration Data set have been included.

Dorsal root ganglion pulsed radiofrequency treatment for chronic cervical radicular pain: a retrospective review of outcomes in fifty-nine cases.

Pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion is used to treat persistent cervical radicular pain that has not responded to conservative therapies. This technique has gained popularity in years for both cervical and lumbosacral radicular pain. The evidence to support its use is still evolving. METHODS: We performed a retrospective review of outcomes in 59 patients who underwent this therapy over a 3-year period in our institution. We evaluated a reduction in pain, duration of pain relief, reduction in use of analgesics and progression to surgery. RESULTS: Our results demonstrated 49 patients experienced some relief. Forty patients of the 59 experienced an improvement in pain of 50% or more. The mean duration of relief in this group was 37 weeks. Seven patients experienced complete resolution of their pain. In this group, the mean duration of relief was 39 weeks. Regarding the 53 patients who were taking medication for pain prior to the procedure, 37 patients reduced or discontinued their usage after the procedure. CONCLUSION: Despite the limitations of a retrospective study, we feel our study adds to the growing evidence base that pulsed radiofrequency treatment adjacent to the cervical dorsal root ganglion has a role in the treatment of chronic cervical radicular pain.

Managing Pain in the Older Cancer Patient.

PURPOSE OF REVIEW: This paper aims to give the specialist and non-specialist alike an overview of the considerations involved in the management of cancer-related pain in the older population. RECENT FINDINGS: Comprehensive guidelines on cancer pain management have been published recently by expert bodies. Cancer pain differs in many respects to other pain conditions and we are likely to encounter it more frequently in older patients in the future. The elderly are more sensitive to the effects of many analgesic medications. The elderly patient with cancer pain presents a unique challenge to the treating physician. The biological effects of ageing impact on the efficacy of many pain management strategies as well as its diagnosis and assessment. Treatment options can be broadly divided into pharmacological, non-pharmacological and interventional. A multidisciplinary approach and frequent re-assessment are essential in achieving favourable outcomes in this patient group.