Articles: analgesia.
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Reg Anesth Pain Med · Dec 2024
Subcostal TAP block: one or two sequential injections? A cadaveric study.
The subcostal transversus abdominis plane block (scTAPB) provides analgesia to the anterior abdominal wall but analgesic spread following a single injection remains modest and variable. The oblique scTAPB, which is performed with a continuous injection during needle progression into the TAP along the oblique subcostal line, may extend the block to the whole anterior abdominal wall but needle progression by hydrodissection may be difficult, explaining why this block is not widely used. This study investigated if two sequential scTAPB injections (2scTAPI) may reach more nerves than a single scTAPB (1scTAPI). ⋯ In a cadaveric model, a larger spread at the costal margin was obtained after 2scTAPI, suggesting a greater coverage of anterior branches of abdominal wall nerves compared with 1scTAPI. Clinical studies are needed to confirm these results.
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Adults with intellectual disability experience more pain than adults without and, despite a higher number of medications being prescribed, may be less likely to receive medication for pain. We conducted a systematic review of existing literature on medication for pain and painful conditions in adults with intellectual disability to explore if there is any association with polypharmacy, multimorbidity or demographic characteristics. ⋯ Adults with intellectual disability may receive less pharmacological management of pain with analgesics and medication for painful conditions despite the high prevalence of polypharmacy, suggesting pain is under-treated. Better assessment and pharmacological treatment of pain and painful conditions is a key future research priority to address this health inequality and improve quality of life for this vulnerable group of people.
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Children make up 5-10% of emergency medical services (EMS) transports and are at risk for under-recognition and under-treatment of pain. Prior studies have identified enablers to pediatric analgesia including EMS pediatric analgesia education, agency leadership support, the availability of assistive guides and having positive relationships with online medical control. Prior barriers identified were intravenous (IV) line insertion pain, caregiver concerns, difficulty assessing pain, pain medication safety concerns, unfamiliarity with pediatrics, unwanted attention from authority figures and perceived superiority of hospital care. This study's objective was to evaluate enablers and barriers to prehospital analgesia for children presenting with traumatic pain after the introduction of intranasal (IN) fentanyl into EMS protocols. ⋯ New enablers for pediatric analgesia identified were longer transports and EMS clinician comfort with IN pain medications. While many barriers to pediatric analgesia persist, new barriers identified were poor suspension in ambulances causing difficulty with IV access and caregivers' lack of knowledge of available prehospital medications. Additional EMS pediatric training and experience may improve pediatric oligoanalgesia.
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Review Practice Guideline
Intrathecal catheter placement after inadvertent dural puncture in the obstetric population: management for labour and operative delivery. Guidelines from the Obstetric Anaesthetists' Association.
Recommendations:
- An intrathecal catheter may be inserted for the provision of analgesia and anaesthesia following inadvertent dural puncture during attempted epidural catheter placement. This decision must be made with consideration of potential risks and benefits (Grade C, moderate level of certainty).
- Whether using intermittent boluses or a continuous infusion technique, use the same local anaesthetic solution throughout labour (Grade I, low level of certainty).
- Maternal blood pressure should be checked every 5 min for 15 min following the first dose, and after every subsequent bolus given via an intrathecal catheter (Grade A, high level of certainty).
- As with epidural analgesia, sensory and motor block should be checked every hour during intrathecal catheter analgesia (Grade B, moderate level of certainty).
- Fetal heart rate should be continuously monitored during intrathecal analgesia (Grade B, moderate level of certainty).
- Top-ups of local anaesthetic for caesarean delivery should be given incrementally, with each bolus limited to 2.5 mg bupivacaine (or equivalent) (Grade I, low level of certainty).
- Extension of labour analgesia for caesarean delivery via an intrathecal catheter should be performed in an operating theatre (Grade B, moderate level of certainty).
- Non-invasive blood pressure, ECG and oxygen saturations should be monitored throughout the duration of intrathecal anaesthesia (Grade A, high level of certainty).
- All departments should have clear guidelines for the management of intrathecal catheters in labour and for delivery. These should highlight key risks, monitoring protocols and other safety measures (Grade A, low level of certainty).
- Only anaesthetists should administer top-ups through an intrathecal catheter, and connect, disconnect or reconnect the catheter and tubing (Grade A, low level of certainty).
- Anaesthetists should account for the dead space of the intrathecal catheter and filter when administering top-ups in labour or for operative delivery (Grade B, low level of certainty).
- An intrathecal catheter should be clearly labelled adjacent to the filter and on the front of any infusion pump (Grade A, low level of certainty).
- The multidisciplinary team (including any non-resident staff who may be called to attend the patient during labour or delivery), must be made aware of the intrathecal catheter through both verbal and written communication, including at every handover (Grade A, low level of certainty).
- Intrathecal catheters should be removed at the earliest opportunity following delivery to reduce the risk of accidental overdose and infectious complications (Grade B, low level of certainty).
- When patients who experience inadvertent dural puncture, with or without intrathecal catheter insertion, are discharged from hospital, follow-up should be in line with established guidance and include written information on headaches, ‘red flag’ symptoms, hospital contact information and communication with primary care (Grade B, low level of certainty).