Anaesthesia & intensive care medicine - Current Issue

Pain is a complex condition and warrants a multidisciplinary approach based on a bio-psycho-social model. Whilst often successful in acute pain, pharmacological treatment is rarely successful on its own in the management of chronic pain due to the high number of patients needed to treat to achieve a clinically meaningful improvement in function, quality of life and pain scores. There are also significant side effects in the short and long term. Recent re-analysis of clinic trial data focused on individual responder rates, showed that there is a cohort of patients who achieve 50% pain relief with subsequent improvement in physical function.

Which of the following are true regarding the pharmacological effects and mechanism of actions of non-opioid analgesics?

Fibromyalgia is a complex condition which can provide a challenge to healthcare professionals. Sufferers experience widespread body pain and debilitating fatigue in addition to cognitive difficulties and sleep disturbance. Group pain management programmes are an evidenced-based approach to providing pain management for people living with chronic pain. Occupational therapists are uniquely placed to provide a holistic approach to patients with chronic pain and a group programme specifically targeted at patients with fibromyalgia has been found to provide an additional benefit of meeting the wide range of challenges they experience.

Physiotherapy is one of the lesser understood but an integral part of chronic pain (CP) management. The complex nature of CP warrants a multidisciplinary approach, addressing the biopsychosocial (BPS) aspects of well-being. This often requires a team of several specialists to assess the burden of individual BPS domains and devise a tailored management programme. Physiotherapy management is based on 3Es – Educate, Empower and Exercise/Movement Interventions. Fear of causing further harm, disability and anxious/low mood associated with it are a common presentation among those living with CP.

During pregnancy, maternal physiology undergoes continual adaptation. These often-interlinked changes occur in all body systems and are affected by the hormonal influences of the placenta and the mechanical adaptations required to accommodate the developing fetus. These important physiological changes can potentially lead to decompensation in parturients with pre-existing comorbidities. They may also unmask asymptomatic pre-pregnancy disease. A sound knowledge of the expected maternal changes is essential to enable accurate interpretation of physiological and laboratory parameters.

Trauma is a significant cause of hospital presentations and admissions in the UK, comprising a diverse selection of patients with differing analgesic needs and levels of comorbidity. Pain from the initial injury and subsequent treatments such as closed reductions and surgery is often severe and can lead to discomfort, difficulty in nursing care physiotherapy, and unwanted admissions. Regional anaesthesia is perfectly placed to provide an individualized analgesic strategy for each trauma patient that gives significant pain relief, and reduces reliance on opiate medications which have a significant side-effect profile especially in the increasingly elderly population presenting to hospitals with trauma.

This article explores mechanisms that generate pain as a multidimensional and embodied construct rather than a simple sensory state. The shortcomings of existing models of pain will be considered alongside contemporary cognitive neuroscience theories of predictive processing, to provide a potential explanation of chronic pain states. The focus is an exploration of integrated corticothalamic-limbic processing as opposed to peripheral nociceptive mechanisms.

Opioids represent an important class of analgesic medication and are effective in moderate to severe acute and cancer pain management. Opioids bind to G protein coupled receptors leading to a variety of physiological effects, including analgesia. Choosing the most appropriate opioid for each individual patient will depend upon the opioids individual pharmacokinetics and pharmacodynamics, their actions across different physiological systems, side effect profiles, available routes of administration and patient factors that impact on drug efficacy.

Which of the following are true about the anatomy and nerve supply of uterus?

Oxygen transport from the atmosphere to the fetus is dependent on maternal, placental and fetal factors. If any of these are disturbed, progressive fetal hypoxia and acidosis occur. Electronic fetal heart rate (FHR) monitoring is considered the primary method to assess fetal condition. Fetal distress refers to the presence of a non-reassurance heart trace, irrespective of the presence or absence of fetal acidosis. Intrauterine fetal resuscitation (IUFR) is a practice designed to enhance oxygen delivery to the placenta and maintain umbilical blood flow to counteract fetal hypoxia and acidosis, enabling safe delivery.

Pain is a sensory and emotional experience that is personal and unique to an individual. Nociception is different from pain and considers the neural process of encoding and processing noxious stimuli. Anatomically noxious stimuli are transduced by nociceptors to an electrical signal carried by first-order neurons to the dorsal horn of the spinal cord. From the spinal cord second-order neurons project in tracts to the thalamus, where third-order neurons continue to higher cerebral centres. There is no known primary pain processing centre in the brain, instead multiple different areas activate and interact in response to noxious stimuli.

Pain is the most common reason for patients to see a doctor. Socio-economic issues including unemployment and difficulty accessing education are common in such patients. Pain is the third leading cause for absence from work. Patients frequently seek support from their multidisciplinary pain team for welfare support and staying in or returning to employment or education. Pain physicians perform a range of intervention procedures and need to have a clear grasp of the law of consent. They are also called on to give expert evidence in personal injury and medical negligence claims where claimants have been left with chronic pain.

Chronic pain is a major cause of disability. Outpatient pain management services take a multidisciplinary approach based on a bio-psychosocial framework, providing assessment and management of patients who suffer from chronic pain. The emphasis is on education and promotion of self-management. Appropriate facilities, management and cohesive working is essential to provide evidence-based effective pain management.

Early identification and anaesthetic assessment of high-risk patients in pregnancy is important and best delivered through a formal assessment clinic. It provides the opportunity to provide information, agree management plans, and carry out necessary investigations and referrals to other specialists prior to labour and delivery. Clear referral criteria and lines of communication are necessary for an effective service.

Paediatric pain is often poorly recognized and undertreated, and managing it effectively can be complex and challenging. Exposure to severe pain without adequate management in childhood can be detrimental and is associated with adverse long-term outcomes such as chronic pain, anxiety and depressive disorders later in life. A multimodal analgesic regimen is recommended, and is just one aspect of a multi-faceted approach to paediatric pain management.The aim of this review is to highlight systemic analgesic options for children, including important considerations for neonates.

Peripheral nerves blocks provide intra- and postoperative analgesia and are an important element of the multimodal approach to perioperative pain. This is particularly important in the paediatric population, where the side effects of opioids, such as respiratory depression, postoperative nausea and vomiting (PONV), and gastrointestinal motility issues, can be especially challenging. The addition of a block to the multimodal strategy allows in most situations for a significant dose reduction in opioid requirements and in some cases to a complete avoidance of opioids.

Sedation of children is often an unavoidable component of many diagnostic and therapeutic healthcare interventions in children. Traditional agents such as chloral hydrate and midazolam continue to be widely used in a safe and effective manner. However, experience with other agents has grown in recent years. This produced more options and shifted attitudes on how sedation may be defined, conceptualized and delivered. This article discusses these changes, as well as covering some of the non-pharmacological factors and issues involved.

Paediatric day case surgery is suitable for many children and procedures, offering benefits to patients, families and organizations. For day surgery units to be successful, thorough processes must be followed to ensure that patients are correctly selected and prepared, lists are organized appropriately, and resources are in place to manage day case smoothly. Techniques for anaesthesia and analgesia should be tailored to facilitate day case discharge with clear information provided to patients and families.