Chronic Post-Surgical Pain after TKR

This was a medical record study that sought to identify the pre-surgical risk factors for chronic post-surgical pain after total knee replacement.

Factors that could predict pain at 5 years in about a third included: fibromyalgia, chronic pain in body parts other than the knee, previous diagnosis of cancer, knee instability, younger age, and presurgical knee pain.

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Cannula based cricothyrotomy

Most experts have shifted to the scalpel technique with bougie for emergency front of neck airway (eFONA).

This high fidelity lab simulation however showed a lesser chance of failure with a cannula based technique and using a Rapid‐O2® cricothyroidotomy insufflation device.

With proper training the authors suggest that there is still a strong case for using a cannula based technique. Much anatomical distortion and difficulty has often been reported with locating the cricothyroid membrane especially in the obese as well as misplacement of the tube.

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Postoperative Sore Throat

This so-called minor complication after general anesthesia was subject to review in this editorial accompanying a study. It has been described in 20-40% of patients.

Risk factors include female, younger age, a history of smoking or lung disease, longer duration of anesthesia, postoperative nausea, natural teeth (vs dentures), blood visible on the endotracheal tube at extubation, intubation techniques and larger diameter tracheal tubes.

Deserving more attention due to its discomfort even though short lived (< 48hours), remedies to reduce its incidence include intravenous dexamethasone, topical benzydamine, topical corticosteroids, lidocaine (either intra-cuff or intravenously administered), ketamine, with even the choice of volatile anesthetic playing a role (desflurane is associated with a higher incidence of POST than sevoflurane).

The editorial references a systematic review and meta-analysis in topical Magnesium. Both dose (100–500 mg, 20 mg·kg−1, or not stated at all) and delivery (gargle, lozenge, or nebulization) of topical magnesium were highly variable. While effective, it needs to be compared to other management strategies.

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Trajectories of Pain Intensity in Adults with Disabling Subacute or Chronic Neck Pain

A randomized study examined pain trajectories over one year in people with the common condition of subacute and chronic neck pain.

The conclusion informs prognosis : “Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over a year. However, a quarter present unfavorable trajectories. High pain intensity at baseline, depressive symptoms, younger age, female sex and sudden onset of pain are factors associated with unfavorable trajectories.”.

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Prolonged Perioperative Use of Pregabalin and Ketamine & Chronic Pain

This was a randomized study in cardiac surgery. Patients were randomly assigned to receive either usual care, pregabalin (150 mg preoperatively and twice daily for 14 postoperative days) alone, or pregabalin in combination with a 48-h postoperative infusion of intravenous ketamine at 0.1 mg · kg−1 · h−1.

Conclusions: Preoperative administration of 150 mg of pregabalin and postoperative continuation twice daily for 14 days significantly lowered the prevalence of persistent pain after cardiac surgery.

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Postoperative Delirium and Cognitive Dysfunction

Based on observational studies, the overlap and divergence between postoperative delirium and short and long term cognitive dysfunction was examined. The effect of surgery and anesthesia on the brain continues to be not clearly understood.

“Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up.”

The authors conclude “Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.”

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Patient Outcomes & Pharmacist Participation in Multidisciplinary Critical Care Teams

This systematic review and meta-analysis studied the effect of pharmacist involvement in critical care.

The results encourage multidisciplinary care beyond medical teams alone:

“Including critical care pharmacists in the multidisciplinary ICU team improved patient outcomes including mortality, ICU length of stay in mixed ICUs, and preventable/nonpreventable adverse drug events.”

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Early Sedation with Dexmedetomidine in Critically Ill Patients

Dexmedetomidine has become an agent touted to reduce delirium, sedate without respiratory depression and improve analgesia in both OR and ICU settings.

This study examined its use as a sole early sedation agent in critically ill patients. Results were not overly impressive.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and and required supplemental sedatives to achieve the prescribed level of sedation. More adverse events were reported in the dexmedetomidine group”

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