Chronic pain after surgery. More than just a nuisance?
Chronic pain can complicate a third of even relatively minor surgical procedures with far-reaching consequences for patient and family. Why does it happen? What can be done to mitigate the problem?
A seminar in three movements held jointly with the Glasgow Southern Medical Society:
'Magnitude' Dr William Macrae, Dundee
'Molecules' Dr Mick Serpell, Glasgow
'Meaning' Dr David Craig, Glasgow
In this lecture, Dr Bill Macrae discusses the magnitude of the problem.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Regional Anesthesia in the Prevention of Persistent Postsurgical PainEdward R. Mariano, MD
Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.
Acute pain management requires a multimodal and multidisciplinary approach with a clear organization framework. Regional anesthesia techniques for surgical anesthesia are a highly effective component of acute pain management.
With the advancement of ultrasonographic technology with higher resolution and penetration imaging, there is increasing use of ultrasonography (US) in acute and chronic pain blocks.
Chronic pain after surgery. More than just a nuisance?
Chronic pain can complicate a third of even relatively minor surgical procedures with far-reaching consequences for patient and family. Why does it happen? What can be done to mitigate the problem?
A seminar in three movements held jointly with the Glasgow Southern Medical Society:
'Magnitude' Dr William Macrae, Dundee
'Molecules' Dr Mick Serpell, Glasgow
'Meaning' Dr David Craig, Glasgow
In this lecture, Dr Bill Macrae discusses the magnitude of the problem.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Regional Anesthesia in the Prevention of Persistent Postsurgical PainEdward R. Mariano, MD
Persistent postsurgical pain (PPSP), or chronic pain that develops after surgery, occurs more frequently than one may expect: up to 50% after relatively common operations. For anesthesiologists, surgeons, and pain physicians, there is an urgent need to discover methods to prevent the development of PPSP which is considered one of the more dreaded adverse outcomes following elective surgery.
Acute pain management requires a multimodal and multidisciplinary approach with a clear organization framework. Regional anesthesia techniques for surgical anesthesia are a highly effective component of acute pain management.
With the advancement of ultrasonographic technology with higher resolution and penetration imaging, there is increasing use of ultrasonography (US) in acute and chronic pain blocks.
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.
Effectiveness and safety of CPNB and continuous local wound infusion
Basal infusion with PCA option
Types of pumps – elastomeric vs. electronic
Outpatient and home infusion pumps
While anesthesiologists globally have had similar interests over the years, the unifying challenge continues to be the selection of outcomes and demonstration of improvement due to the anesthesiologist’s role and/or choice of anesthetic or analgesic technique.
Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
Pain is not “just a symptom”. It is a significant biomedical problem that requires expertise, and merits study in its own right
awareness
education
research
At the conclusion of this activity, learners will be able to: discuss the benefits of regional anesthesia on pain and rehabilitative outcomes; identify applications of “big data” in outcomes assessment; and critically evaluate the evidence related to regional anesthesia and analgesia and long-term outcomes.
Pain Physicians should consider nerve blocks when systemic analgesics are failing. (Adjuvant therapy)
Careful selection of patients
Benefits should outweigh the risks
Thorough knowledge of the limitations and side effects
Need for randomized controlled clinical trials.
Total knee replacement (TKR) is one of the most commonly done surgical procedures, with over 150,000 total knee replacements and THR performed annually in England and Wales in the National Health Service (NHS). In India although clear-cut data is not available but the incidence is increasing. In the US, 431,000 TKRs are performed yearly and the utilization of TKR has increased over the last two decades, especially among younger patients .TKR may be associated with severe post-operative pain. The International Association for the Study of Pain (IASP) has defined pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made adequate pain management a priority and has deemed monitoring pain as the “fifth” vital sign.
Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.
Effectiveness and safety of CPNB and continuous local wound infusion
Basal infusion with PCA option
Types of pumps – elastomeric vs. electronic
Outpatient and home infusion pumps
While anesthesiologists globally have had similar interests over the years, the unifying challenge continues to be the selection of outcomes and demonstration of improvement due to the anesthesiologist’s role and/or choice of anesthetic or analgesic technique.
Trauma is one of the primary causes of mortality and morbidity worldwide, and pain is the most common symptom reported by patients entering the Emergency Department. More than 5 million people in the United States report long-term disabilities due to traumatic injuries. Safe intraoperative care and effective acute pain management are essential for successful outcomes in the trauma patient.
Get Rid of Your Traditional Acute Pain Service and Broaden Your Vision!Edward R. Mariano, MD
Our biggest challenge (and also opportunity) is to demonstrate our value as anesthesiologists and pain medicine specialists in the evolving healthcare landscape. Going forward, physician anesthesiologists need to take on leadership roles in coordinating patient care, including by not limited to pain medicine, by collaborating with primary care, surgery, nursing, physical therapy, pharmacy, social work, and other hospital-based services.
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
Pain is not “just a symptom”. It is a significant biomedical problem that requires expertise, and merits study in its own right
awareness
education
research
At the conclusion of this activity, learners will be able to: discuss the benefits of regional anesthesia on pain and rehabilitative outcomes; identify applications of “big data” in outcomes assessment; and critically evaluate the evidence related to regional anesthesia and analgesia and long-term outcomes.
Post operative pain management has no specific criteria. Lots of methods and procedures are suggested with various types of drugs. It is just a guideline for management of pain after surgery.
Pregabalin is an effective and safe adjuvant for reducing chronic
post-thoracotomy pain, without significant side effects, in all age
groups and either gender. The pain relief becomes statistically
significant after three weeks of treatment and it continues till six
months. However, larger randomized and placebo-controlled trials
of longer durations are required to further validate these findings.
This presentation was delivered during a webinar held by the association of anaesthetists in association with RA-UK entitled "New Blocks - Friend or Foe?".
This took place on 19th October 2021.
In this short presentation - Dr Pawa covers: a brief overview of the history of Paravertebral blocks; how he got introduced to them; some updates on our understanding on the anatomy; and whether they still have a role in modern anaesthetic practice.
The Anesthesiologist, especially young, faces a major challenge when faced with very ill/ severly moribund, elderly, cachwexic patients with history of fall and lower extremity fractures for elective or ortho surgical procedure. Prof. mridul m. panditrao, explains various problems faced especially with GA, and the best alternatives. Two different approaches of Combined spinal epidual are discussed, with use of adjuvants and also his own randomizede trial and experience.
Preemptive Analgesia for Attenuation of Postoperative Pain in Patients Underg...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Expanding the Field of Radiation Therapy for
Malignant Pleural Mesothelioma presented by Kenneth Rosenzweig, MD of Mount Sinai School of Medicine at the Mesothelioma Applied Research Foundation in New York, NY on September 28, 2012. www.curemeso.org
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. Colin J.L. McCartneyColin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of AnaesthesiaProfessor and Chair of Anaesthesia
University of OttawaUniversity of Ottawa
Head of AnaesthesiaHead of Anaesthesia
The Ottawa HospitalThe Ottawa Hospital
Scientist,Scientist,
Ottawa Hospital Research InstituteOttawa Hospital Research Institute
Chronic Pain after Surgery:Chronic Pain after Surgery:
Does it exist and can weDoes it exist and can we
prevent it?prevent it?
2. Objectives (25 mins)Objectives (25 mins)
Understand incidence of CPSP (5 mins)Understand incidence of CPSP (5 mins)
Who are the populations at risk? (5 mins)Who are the populations at risk? (5 mins)
What new approaches exist for preventingWhat new approaches exist for preventing
CPSP? (10 mins)CPSP? (10 mins)
What does the future hold? (5 mins)What does the future hold? (5 mins)
3. SummarySummary
CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
Preoperative pain and psychological factorsPreoperative pain and psychological factors
major predictorsmajor predictors
Prevention possible with high qualityPrevention possible with high quality
perioperative pain relief including LA techniquesperioperative pain relief including LA techniques
and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach
Future management possibilities include novelFuture management possibilities include novel
therapeutic, psychological andtherapeutic, psychological and
pharmacogenomic approachespharmacogenomic approaches
4. Incidence ofIncidence of
Chronic Post-Surgical PainChronic Post-Surgical Pain
Pain after surgery of primary concern toPain after surgery of primary concern to
patients (Apfelbaum et al 1999)patients (Apfelbaum et al 1999)
Acute postoperative pain remainsAcute postoperative pain remains
undertreatedundertreated
Incidence of severe acute pain a problemIncidence of severe acute pain a problem
Severe acute pain associated with CPSPSevere acute pain associated with CPSP
Definition: pain >2 months after surgeryDefinition: pain >2 months after surgery
7. 300 patients300 patients
2/3 had moderate-severe pain after2/3 had moderate-severe pain after
surgerysurgery
No change from 10 years earlierNo change from 10 years earlier
Gan TJ et al CMRO 2014
15. Systematic review. 281 studies assessedSystematic review. 281 studies assessed
investigating PSPS in 11 surgical typesinvestigating PSPS in 11 surgical types
Prevalence of NeuP determined using NeuPPrevalence of NeuP determined using NeuP
grading systemgrading system
Prevalence of NeuP high after thoracic andPrevalence of NeuP high after thoracic and
breast surgery (66/68%). 31% after groin herniabreast surgery (66/68%). 31% after groin hernia
repair and 6% after THA and TKArepair and 6% after THA and TKA
Prevalence of PneuP varies by type of surgeryPrevalence of PneuP varies by type of surgery
and probability of nerve injuryand probability of nerve injury
16. Risk Factors for CPSP?Risk Factors for CPSP?
Preoperative: Pain, Repeat surgery,Preoperative: Pain, Repeat surgery,
Psychological factors, Female gender andPsychological factors, Female gender and
younger age, Genetic predispositionyounger age, Genetic predisposition
Intraoperative: Surgical approach andIntraoperative: Surgical approach and
risks of nerve injuryrisks of nerve injury
Postoperative: Acute Pain, Radiation Rx,Postoperative: Acute Pain, Radiation Rx,
Neurotoxic chemotherapy, Anxiety andNeurotoxic chemotherapy, Anxiety and
Depression, NeuroticismDepression, Neuroticism
McIntyre et al 2010
17. What can we do about theWhat can we do about the
problem?problem?
Regional anaesthesia techniquesRegional anaesthesia techniques
Systemic drug interventionsSystemic drug interventions
Modified surgical techniquesModified surgical techniques
Focus on postoperative pain controlFocus on postoperative pain control
19. 23 RCTs in total23 RCTs in total
Pooled 3 studies for epidural afterPooled 3 studies for epidural after
thoracotomy and 2 for PVB after breastthoracotomy and 2 for PVB after breast
surgerysurgery
Unable to pool data from other studies dueUnable to pool data from other studies due
to marked heterogeneityto marked heterogeneity
25. No long term benefit for:No long term benefit for:
– GabapentinGabapentin
– PregabalinPregabalin
– NSAIDSNSAIDS
– CorticosteroidsCorticosteroids
– MexilitineMexilitine
2013 Cochrane Collaboration
31. Preoperative painPreoperative pain
Pain catastrophizingPain catastrophizing
Mental healthMental health
Pain at other sitesPain at other sites
37. Genetics of PainGenetics of Pain
3 variants (haplotypes) of gene encoding3 variants (haplotypes) of gene encoding
COMT predicting low, moderate and highCOMT predicting low, moderate and high
sensitivity to painsensitivity to pain
Encompass 96% of humansEncompass 96% of humans
Low COMT levels predict high painLow COMT levels predict high pain
sensitivity and risk of developing TMDsensitivity and risk of developing TMD
Inhibition of COMT in rat model increasesInhibition of COMT in rat model increases
pain sensitivitypain sensitivity
Diatchenko L et al 2005
38. CPSP is likely 50% influenced by geneticCPSP is likely 50% influenced by genetic
determinantsdeterminants
Identifying genetic basis of CPSP couldIdentifying genetic basis of CPSP could
lead to significant improvement inlead to significant improvement in
treatmenttreatment
Prediction of CPSP, PharmacogenomicsPrediction of CPSP, Pharmacogenomics
Improved treatmentsImproved treatments
CJA: published ahead of print
39. Novel neuroactive agentsNovel neuroactive agents
Not analgesic per seNot analgesic per se
Prevent mechanism of transition to chronicPrevent mechanism of transition to chronic
painpain
rhBDNF, neuroprotective agents (e.g.rhBDNF, neuroprotective agents (e.g.
acetyl l-carnitine) and anti-oxidantsacetyl l-carnitine) and anti-oxidants
Early promising resultsEarly promising results
Bordet T et al Neurotherapeutics 2009
40. SummarySummary
CPSP common and varies by type of surgeryCPSP common and varies by type of surgery
Preoperative pain and psychological factorsPreoperative pain and psychological factors
major predictorsmajor predictors
Prevention possible with high qualityPrevention possible with high quality
perioperative pain relief including LA techniquesperioperative pain relief including LA techniques
and NMDA antagonists and surgical approachand NMDA antagonists and surgical approach
Future management possibilities include novelFuture management possibilities include novel
therapeutic, psychological andtherapeutic, psychological and
pharmacogenomic approachespharmacogenomic approaches
41. Good Acute Pain Control MajorGood Acute Pain Control Major
Concern for PatientsConcern for Patients
Apfelbaum et al A&A 2003
42. Acute pain controlAcute pain control
Use regional anaesthesia where possibleUse regional anaesthesia where possible
Use NSAIDS, paracetamol in multimodalUse NSAIDS, paracetamol in multimodal
regimenregimen
For higher risk cases use ketamine and/orFor higher risk cases use ketamine and/or
lidocaine infusion during surgerylidocaine infusion during surgery
Gabapentin/Pregabalin useful for acuteGabapentin/Pregabalin useful for acute
pain control and reduction of opioidpain control and reduction of opioid
consumptionconsumption
Editor's Notes
Good morning. My name is Colin McCartney and I am an anesthetist and consultant in chronic pain management from Toronto Western Hospital.