Preventive analgesia:
Broader definition of preemptive analgesia
Perioperative analgesic regimen that able to control pain-induced sensitization
Not the timing of the analgesic treatment but the duration and efficacy of an analgesic intervention are more important for an effective postoperative pain relief
Adequate preventive analgesia should include multimodal techniques and with a sufficient duration of tretment
Preventive analgesia:
Broader definition of preemptive analgesia
Perioperative analgesic regimen that able to control pain-induced sensitization
Not the timing of the analgesic treatment but the duration and efficacy of an analgesic intervention are more important for an effective postoperative pain relief
Adequate preventive analgesia should include multimodal techniques and with a sufficient duration of tretment
PCA is neither “ one size fits all “ or a “ set and forget “ therapy
An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take care
Paracetamol iv as a single analgesic is very safe analgesic, but only for mild and moderate pain.
It can be combined with many analgesic or adjuvan drugs to provide strong analgesic for postoperative pain.
So, it can be the basic regiment for Multimodal Analgesia.
Because of its safety it can be the choice for high risk surgical patient
Patient Controlled Analgesia: Return to Nursing ProgramIHNA Australia
This presentation outlines how nurses can use Patient Controlled Analgesia (PCA) to benefit patients/clients. This presentation covers:
1. Indications and contraindications of PCA use
2. The advantages of PCA
and
3. The pharmacological principles of pain management
This presentation was compiled by Gulzar Malik, an experienced and qualified Nursing Educator at IHNA. For more information about our return to nursing programs, please call 1800 22 52 83.
PCA is neither “ one size fits all “ or a “ set and forget “ therapy
An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take care
Paracetamol iv as a single analgesic is very safe analgesic, but only for mild and moderate pain.
It can be combined with many analgesic or adjuvan drugs to provide strong analgesic for postoperative pain.
So, it can be the basic regiment for Multimodal Analgesia.
Because of its safety it can be the choice for high risk surgical patient
Patient Controlled Analgesia: Return to Nursing ProgramIHNA Australia
This presentation outlines how nurses can use Patient Controlled Analgesia (PCA) to benefit patients/clients. This presentation covers:
1. Indications and contraindications of PCA use
2. The advantages of PCA
and
3. The pharmacological principles of pain management
This presentation was compiled by Gulzar Malik, an experienced and qualified Nursing Educator at IHNA. For more information about our return to nursing programs, please call 1800 22 52 83.
Percura, Improve Pain and Numbness Associated with Peripheral NeuropathyTargeted Medical Pharma
Percura capsules by oral administration. A specially formulated Medical Food product, consisting of a proprietary blend of amino acids in specific proportions, for the dietary management of the metabolic processes associated with pain, inflammation and loss of sensation due to peripheral neuropathy. Must be administered under physician supervision.
Percura is a proprietary formulation of amino acids and other dietary factors to support induction, maintenance, and enhancement of the specific neurotransmitter activity involved in the physiology of neuropathic pain. The formulation consists of nonessential and essential amino acids L-Arginine HCL, L-Histidine HCL, L-Glutamine, L-Serine, L-Lysine, L-Ornithine, Acetyl L-Carnitine, L-Tyrosine, the nonstandard amino acid Gamma Aminobutyric Acid, Choline Bitartrate, Glucose, Inositol, Griffonia Extract griffonia simplicifolia (95% 5-HTP) , and Creatine. These ingredients fall into the classification of Generally Recognized as Safe (GRAS) as defined by the Food and Drug Administration (FDA) (Sections 201(s) and 409 of the Federal Food, Drug, and Cosmetic Act). A GRAS substance is distinguished from a food additive on the basis of the common knowledge about the safety of the substance for its intended use. The standard for an ingredient to achieve GRAS status requires not only technical demonstration of non-toxicity and safety, but also general recognition of safety through widespread usage and agreement of that safety by experts in the field. Many ingredients have been determined by the FDA to be GRAS, and are listed as such by regulation, in Volume 21 Code of Federal Regulations (CFR) Sections 182, 184, and 186.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Introduction
Critically ill patients more medications
Opioids have been the mainstay of pain control and sedation in the ICU, despite
substantial adverse consequences
Long term opioid use tolerance, dependence, withdrawal
Chronic pain & opioid induced hyperalgeusia
Cullen DJ, Sweitzer BJ, Bates DW, Burdick E, Edmondson A, Leape LL. Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. Crit Care Med 1997; 25: 1289-97.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306.
Roeckel LA, Le Coz GM, Gaveriaux-Ruff C, Simonin F. Opioid-induced hyperalgesia: cellular and molecular mechanisms. Neuroscience 2016; 338: 160-82.
Chu LF, Angst MS, Clark D. Opioidinduced hyperalgesia in humans: molecular mechanisms and clinical considerations. Clin J Pain 2008; 24: 479-96.
Puntillo KA, Naidu R. Chronic pain disorders after critical illness and ICUacquired opioid dependence: two clinical conundra. Curr Opin Crit Care 2016; 22: 506-12.
3. Opioid Tolerance
Opioid tolerance: less susceptibility to the effects of the opioid, which can result in
a need for higher and more frequent doses to achieve the same analgesic effect
Opioid tolerance can be seen during all types of critical illnesses; especially in
major trauma (e.g., burn injury), in patients requiring prolonged mechanical
ventilation, and in pediatric patients
Tolerance due to high dose and inflammatory response
Bittner EA, Shank E, Woodson L, Martyn JA. Acute and perioperative care of the burn-injured patient. Anesthesiology 2015; 122: 448-64.
Anand KJ, Willson DF, Berger J, et al. Tolerance and withdrawal from prolonged opioid use in critically ill children. Pediatrics 2010; 125(5): e1208-e1225.
Wang Y, Mitchell J, Moriyama K, et al. Age-dependent morphine tolerance development in the rat. Anesth Analg 2005; 100: 1733-9.
4. Mendell JR, Sahenk Z. Painful sensory neuropathy. N Engl J Med 2003; 348: 1243-55.
5. Indication of Opioid
Critical illness patients moderate to severe pain distressing and
underrecognized
Source of pain: The underlying illness or surgery, placement of penetrating
invasive tubes or catheters, and other routine intensive care procedures
Patients cannot communicate: endotracheal intubation, sedation, neuromuscular
blockers, altered mental status, physical restraints, and other disease-related
complications
Analgeusia first sedation (analgosedation): is a strategy for managing pain and
discomfort that relies on analgesic agents first, before sedatives
Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S. A prospective study of pain at rest: incidence and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit patients. Anesthesiology 2007; 107: 858-60.
Puntillo KA, Max A, Timsit JF, et al. Determinants of procedural pain intensity in the intensive care unit: the Europain study. Am J Respir Crit Care Med 2014; 189: 39-47.
Chanques G, Pohlman A, Kress JP, et al. Psychometric comparison of three behavioural scales for the assessment of pain in critically ill patients unable to self-report. Crit Care 2014; 18: R160.
Faust AC, Rajan P, Sheperd LA, Alvarez CA, McCorstin P, Doebele RL. Impact of an analgesia-based sedation protocol on mechanically ventilated patients in a medical intensive care unit. Anesth Analg 2016; 123: 903-9.
Devabhakthuni S, Armahizer MJ, Dasta JF, Kane-Gill SL. Analgosedation: a paradigm shift in intensive care unit sedation practice. Ann Pharmacother 2012; 46: 530-40.
Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306
6. Unrelieved Pain Consequences
Unrelieved pain affects physiological and psychological function
most of which are due to exacerbation of the stress responses induced by
catecholamines, glucocorticoids, and antidiuretic-hormone release
Stress activation of the hypothalamic–pituitary–adrenal axis and the renin–
angiotensin–aldosterone axis can lead to fluid retention, generalized edema, and
hypertension
Other adverse consequences of stress include impaired tissue oxygenation, wound
healing, and immunity, increased myocardial and total oxygen consumption and
muscle catabolism; and neuroinflammatory priming
Chapman CR, Tuckett RP, Song CW. Pain and stress in a systems perspective: reciprocal neural, endocrine, and immune interactions. J Pain 2008; 9: 122-45.
Tennant F. The physiologic effects of pain on the endocrine system. Pain Ther 2013; 2: 75-86.
Finnerty CC, Mabvuure NT, Ali A, Kozar RA, Herndon DN. The surgically induced stress response. JPEN J Parenter Enteral Nutr 2013; 37: Suppl: 21S-29S.
Wohleb ES, McKim DB, Sheridan JF, Godbout JP. Monocyte trafficking to the brain with stress and inflammation: a novel axis of immune-to-brain communication that influences mood and behavior. Front Neurosci 2015; 8: 447.
Fonken LK, Weber MD, Daut RA, et al. Stress-induced neuroinflammatory priming is time of day dependent. Psychoneuroendocrinology 2016; 66: 82-90.
Anderson BJ, Mikkelsen ME. Stressing the brain: the immune system, hypothalamic-pituitary-adrenal axis, and psychiatric symptoms in acute respiratory distress syndrome survivors. Ann Am Thorac Soc 2017; 14: 839-41.
7. Psychological Consequences
Anxiety
Depression
Impaired sleep
Demoralization
a risk factor for subsequent post-traumatic stress disorder
Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain 2013; 14: 1539-52.
8. Risk Factors For The Development Of
Persistent Pain
Pain are poorly controlled
High-intensity
Acute pain
Preoperative pain or anxiety
Long-term opioid use
A relatively long ICU stay
Major surgery
Jiang X, Orton M, Feng R, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg 2017; 265: 722-7.
9. Martyn JJ, Mao J, Bittner EA. Opioid Tolerance in Critical Illness. New England Journal of Medicine. 2019 Jan 24;380(4):365-78.
10. de Goeij M, van Eijk LT, Vanelderen P, et al. Systemic inflammation decreases pain threshold in humans in vivo. PLoS One 2013; 8(12): e84159.
Nyland JE, McLean SA, Averitt DL. Prior stress exposure increases pain behavior in a rat model of full thickness thermal injury. Burns 2015; 41: 1796-804
11. de Goeij M, van Eijk LT, Vanelderen P, et al. Systemic inflammation decreases pain threshold in humans in vivo. PLoS One 2013; 8(12): e84159.
Nyland JE, McLean SA, Averitt DL. Prior stress exposure increases pain behavior in a rat model of full thickness thermal injury. Burns 2015; 41: 1796-804
12. Strategies for Mitigating Opioid Tolerance or
Opioid-Induced Hyperalgesia
Appropriate use of opioids
Coadministration of nonopioid analgesics as rescue therapy during
procedures or to potentiate the effects of opioids
Continuous administration of nerve blocks by means of a catheter
Prevention or reversal of opioid-induced hyperalgesia and opioid-withdrawal
symptoms
Reduction of inflammation
Martyn JJ, Mao J, Bittner EA. Opioid Tolerance in Critical Illness. New England Journal of Medicine. 2019 Jan 24;380(4):365-78.
13. Appropriate Use Of Opioids
Use of valid assessment scales of pain before and during administration of the
analgesic drug
Use of intermittent opioid therapy (oral or intravenous) rather than continuous
infusions, when possible
Opioid rotation Use of remifentanil for short-term analgesia (because of potent
induction of opioid-induced hyperalgesia), except when rapid offset of effect is
required, as in evaluation of head injury
Minimal use of benzodiazepines (because of delirium and potential opioid-induced
hyperalgesia associated with long-term use)
Avoidance of excessive dose escalation
Supplementation of opioid with nonopioid analgesics
Addition of methadone to attenuate or delay opioid tolerance
Martyn JJ, Mao J, Bittner EA. Opioid Tolerance in Critical Illness. New England Journal of Medicine. 2019 Jan 24;380(4):365-78.
14. Non-Opioid Analgeusia
N-methyl-d-aspartate receptor antagonists (ketamine)
α2-Adrenergic receptor agonists (clonidine or dexmedetomidine)
Gabapentinoids (gabapentin or pregabalin)
Kumar K, Kirksey MA, Duong S, Wu CL. A review of opioid-sparing modalities in perioperative pain management: methods to decrease opioid use postoperatively. Anesth Analg 2017; 125: 1749-60.
Mion G, Villevieille T. Ketamine pharmacology: an update (pharmacodynamics and molecular aspects, recent findings). CNS Neurosci Ther 2013; 19: 370-80.
Costi S, Van Dam NT, Murrough JW. Current status of ketamine and related therapies for mood and anxiety disorders. Curr Behav Neurosci Rep 2015; 2: 216-25.
Wang JG, Belley-Cote E, Burry L, et al. Clonidine for sedation in the critically ill: a systematic review and meta-analysis. Crit Care 2017; 21: 75.
Quintero GC. Review about gabapentin misuse, interactions, contraindications and side effects. J Exp Pharmacol 2017; 9: 13-21.
15. Neuraxial and Non-neuraxial Analgeusia
Neuraxial: thoracic or lumber epidural blocks for thoracic, abdominal, or bilateral
leg analgesia
Regional: brachial plexus block for arm analgesia; femoral or obturator block or
both, with or without sciatic nerve block for lower-limb analgesia
Local: paravertebral block for rib fractures or chest-tube–associated pain;
transversus abdominis block for lower abdominal surgery
Capdevila M, Ramin S, Capdevila X. Regional anesthesia and analgesia after surgery in ICU. Curr Opin Crit Care 2017; 23: 430-9.
De Pinto M, Dagal A, O’Donnell B, Stogicza A, Chiu S, Edwards WT. Regional anesthesia for management of acute pain in the intensive care unit. Int J Crit Illn Inj Sci 2015; 5: 138-43.
Wiebalck A, Grau T. Ultrasound imaging techniques for regional blocks in intensive care patients. Crit Care Med 2007; 35: Suppl: S268-S274.
16. Prevention Or Reversal Of
Opioid-induced Hyperalgesia And
Opioid-withdrawal Symptoms
Tapering of opioid dose when pain score goal is achieved (10–20% dose reduction
every 1–4 days)
Use of valid withdrawal assessment scales
Use of adjuncts to opioids (ketamine, dexmedetomidine, or gabapentinoids
[gabapentin or pregabalin])
Use of methadone
Martyn JJ, Mao J, Bittner EA. Opioid Tolerance in Critical Illness. New England Journal of Medicine. 2019 Jan 24;380(4):365-78.
17. Reduction of Inflammation
Scheduled acetaminophen therapy
Short-term use of ketorolac
McDaid C, Maund E, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review. Health Technol
Assess 2010; 14: 1-153, iii-iv.
Wick EC, Grant MC, Wu CL. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques: a review. JAMA Surg 2017; 152: 691-7.
18. Future Directions
Modulation of Immune Responses α7 nicotinic acetylcholine receptor agonists
Cannabinoids
Buprenorphine with or without Naloxone and Methadone
Other Drugs and Considerations; Lidocaine, β-adrenoceptor antagonists,
magnesium, tricyclic antidepressants, antipsychotics
Martyn JJ, Mao J, Bittner EA. Opioid Tolerance in Critical Illness. New England Journal of Medicine. 2019 Jan 24;380(4):365-78.
19. Summary
In patients with critical illness, opioid is needed
However, long-term opioid use has detrimental effects, including analgesic
tolerance, which drives dose escalation and leads to opioid-induced hyperalgesia
Strategy: appropriate use of opioid and multimodal therapy
