Pain management in chronic pancreatitis

Pain in chronic pancreatitis(CP)is difficult to manage.Many patients suffer from inadequate pain relief,completely incapacitating them in their daily activities.Historically,despite their well-known adverse effects,opioids have been the pillar of treatment regimens in painful CP.The management is now gradually evolving with a better understanding of the underlying pathophysiology of CP-related pain.Clinicians should follow a holistic approach to the management of CPassociated pain,which must involve lifestyle changes that are coupled with analgesic medications and other pain-relieving interventions.Furthermore,there is no easy cure for vanquishing CP-associated pain.Each patient must be evaluated on a case-by-case basis by a multidisciplinary team to decide which treatment option is best suited for that individual.

Recent advances in managing obstructive sleep apnea

Obstructive sleep apnea(OSA)is a rapidly increasing global concern.If it remains untreated,it can lead to cardiovascular,metabolic,and psychiatric complications and may result in premature death.The efficient and effective management of OSA can have a beneficial effect and help reduce the financial burden on the health sector.There has been constant development in OSA management,and numerous options are available.The mainstay of therapy is still the conventional measures and behavioral modifications.However,in cases of failure of these modalities,surgical therapy is the only option.Numerous studies have shown that proper management of OSA has beneficial effects with good long-term outcomes.

Multidisciplinary approach toward enhanced recovery after surgery for total knee arthroplasty improves outcomes

Knee osteoarthritis is a degenerative disorder of the knee,which leads to joint pain,stiffness,and inactivity and significantly affects the quality of life.With an increased prevalence of obesity and greater life expectancies,total knee arthroplasty(TKA)is now one of the major arthroplasty surgeries performed for knee osteoarthritis.When enhanced recovery after surgery(ERAS)was introduced in TKA,clinical outcomes were enhanced and the economic burden on the healthcare system was reduced.ERAS is an evidence-based scientific protocol aimed at ameliorating the surgical stress response.ERAS aims to enhance the recovery phase,which encompasses multidisciplinary strategies at every step of perioperative care,including the rehabilitation phase.Implementation of ERAS in TKA aids in reducing the length of hospital stay,improving pain management,reducing perioperative complications,and enhancing patient satisfaction.Multidisciplinary collaboration,integrating the expertise of anesthesiologists,orthopedic surgeons,nursing personnel,and other healthcare professionals,is the cornerstone of ERAS in patients undergoing TKA.

Perioperative cardiac risks in myasthenia gravis

Myasthenia gravis(MG)is an autoimmune disorder that affects the neuromuscular junction.The primary pathology in MG involves the presence of autoantibodies to acetylcholine receptors(AChRs),which results in qualitative and quantitative reductions in the availability of functional AChRs.Cardiac muscles are also affected,resulting in various perioperative cardiac complications.Antistriational antibodies are commonly reported in MG cases with cardiac involvement.In the presence of thymoma,the prevalence of cardiac manifestations in patients with MG increases to approximately 10%-15%.Cardiac involvement in MG may range from asymptomatic electrocardiogram changes to ventricular tachycardia,myocarditis,conduction disorders,heart failure,and sudden death.Increased incidence of atrial fibrillation,ventricular and supraventricular extra systoles,and prolonged QTc have also been reported in patients with MG.Clinicians should consider the evaluation of autonomic dysfunction and risk of cardiovascular disease in patients with MG.

Pitfalls in internal jugular vein cannulation

Central venous catheter insertion in the internal jugular vein(IJV)is frequently performed in acute care settings,facilitated by its easy availability and increased use of ultrasound in healthcare settings.Despite the increased safety profile and insertion convenience,it has complications.Herein,we aim to inform readers about the existing literature on the plethora of complications with potentially disastrous consequences for patients undergoing IJV cannulation.

Stroke:Evolution of newer treatment modalities for acute ischemic stroke

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide.Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes.However,there has been a paradigm shift in the management approach over the last decade,and with the emphasis currently directed toward including newer modalities such as neuroprotection,stem cell treatment,magnetic stimulation,anti-apoptotic drugs,delayed recanali-zation,and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

Relevance of sleep for wellness:New trends in using artificial intelligence and machine learning

Sleep and well-being have been intricately linked,and sleep hygiene is paramount for developing mental well-being and resilience.Although widespread,sleep disorders require elaborate polysomnography laboratory and patient-stay with sleep in unfamiliar environments.Current technologies have allowed various devices to diagnose sleep disorders at home.However,these devices are in various validation stages,with many already receiving approvals from competent authorities.This has captured vast patient-related physiologic data for advanced analytics using artificial intelligence through machine and deep learning applications.This is expected to be integrated with patients’Electronic Health Records and provide individualized prescriptive therapy for sleep disorders in the future.

Current evidence on artificial intelligence in regional anesthesia

The recent advancement in regional anesthesia(RA)has been largely attributed to ultrasound technology.However,the safety and efficiency of ultrasound-guided nerve blocks depend upon the skill and experience of the performer.Even with adequate training,experience,and knowledge,human-related limitations such as fatigue,failure to recognize the correct anatomical structure,and unintentional needle or probe movement can hinder the overall effectiveness of RA.The amalgamation of artificial intelligence(AI)to RA practice has promised to override these human limitations.Machine learning,an integral part of AI can improve its performance through continuous learning and experience,like the human brain.It enables computers to recognize images and patterns specifically useful in anatomic structure identification during the performance of RA.AI can provide real-time guidance to clinicians by highlighting important anatomical structures on ultrasound images,and it can also assist in needle tracking and accurate deposition of local anesthetics.The future of RA with AI integration appears promising,yet obstacles such as device malfunction,data privacy,regulatory barriers,and cost concerns can deter its clinical implementation.The current mini review deliberates the current application,future direction,and barrier to the application of AI in RA practice.

Adjuvants to local anesthetics: Current understanding and future trends

Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by itsduration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. A large array of opioids ranging from morphine, fentanyl and sufentanyl to hydromorphone, buprenorphine and tramadol has been used with varying success. However, their use has been limited by their adverse effect like respiratory depression, nausea, vomiting and pruritus, especially with its neuraxial use. Epinephrine potentiates the local anesthetics by its antinociceptive properties mediated by alpha-2 adrenoreceptor activation along with its vasoconstrictive properties limiting the systemic absorption of local anesthetics. Alpha 2 adrenoreceptor antagonists like clonidine and dexmedetomidine are one of the most widely used class of local anesthetic adjuvants. Other drugs like steroids(dexamethasone), anti-inflammatory agents(parecoxib and lornoxicam), midazolam, ketamine, magnesium sulfate and neostigmine have also been used with mixed success. The concern regarding the safety profile of these adjuvants is due to its potential neurotoxicity and neurological complications which necessitate further research in this direction. Current research is directed towards a search for agents and techniques which would prolong local anaesthetic action without its deleterious effects. This includes novel approaches like use of charged molecules to produce local anaesthetic action(tonicaine and n butyl tetracaine), new age delivery mechanisms for prolonged bioavailability(liposomal, microspheres and cyclodextrin systems) and further studies with other drugs(adenosine, neuromuscular blockers, dextrans).

Intracranial pressure monitoring:Gold standard and recent innovations

Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate noninvasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortionproduct oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.

Vasopressors in obstetric anesthesia: A current perspective

Vasopressors are routinely used to counteract hypotension after neuraxial anesthesia in Obstetrics. The understanding of the mechanism of hypotension and the choice of vasopressor has evolved over the years to a point where phenylephrine has become the preferred vasopressor. Due to the absence of definitive evidence showing absolute clinical benefit of one over the other, especially in emergency and high-risk Cesarean sections, our choice of phenylephrine over the other vasopressors like mephentermine, metaraminol, and ephedrine is guided by indirect evidence on fetalacid-base status. This review article evaluates the present day evidence on the various vasopressors used in obstetric anesthesia today.

Biochemical changes in the injured brain

Brain metabolism is an energy intensive phenomenon involving a wide spectrum of chemical intermediaries. Various injury states have a detrimental effect on the biochemical processes involved in the homeostatic and electrophysiological properties of the brain. The biochemical markers of brain injury are a recent addition in the armamentarium of neuro-clinicians and are being increasingly used in the routine management of neuropathological entities such as traumatic brain injury, stroke, subarachnoid haemorrhage and intracranial space occupying lesions. These markers are increasingly being used in assessing severity as well as in predicting the prognostic course of neuro-pathological lesions. S-100 protein, neuron specific enolase, creatinine phosphokinase isoenzyme BB and myelin basic protein are some of the biochemical markers which have been proven to have prognostic and clinical value in the brain injury. While S-100, glial fibrillary acidic protein and ubiquitin C terminal hydrolase are early biomarkers of neuronal injury and have the potential to aid in clinical decisionmaking in the initial management of patients presenting with an acute neuronal crisis, the other biomarkers are of value in predicting long-term complications and prognosis in such patients. In recent times cerebral microdialysis has established itself as a novel way of monitoring brain tissue biochemical metabolites such as glucose, lactate, pyruvate, glutamate and glycerol while small non-coding RNAs have presented themselves as potential markers of brain injury for future.

Comparative analysis of APACHE-Ⅱ and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy

BACKGROUND Laparotomy remains one of the commonest emergency surgical procedures.Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment. Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources. Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity(P-POSSUM) and the acute physiology and chronic health evaluation Ⅱ(APACHE-Ⅱ) have been the most widely used scoring systems for emergency laparotomies. It is always better to have a single scoring system to predict outcomes and audit healthcare organizations.AIM To compare the ability of APACHE-Ⅱ and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy.METHODS All patients undergoing emergency laparotomy at the Tata Main Hospital,Jamshedpur between December 2013 and November 2014 were included in the study. In this observational study, P-POSSUM and APACHE-Ⅱ scoring were done, and the outcome analysis evaluated with mortality being the primary outcome.RESULTS For P-POSSUM, at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis, the area under the curve was 0.989; and for APACHE-Ⅱ, at the cut off value of 24, the area under the curve was 0.965.CONCLUSION Because the ability of APACHE-Ⅱ to predict mortality was similar to P-POSSUM and APACHE-Ⅱ does not need scoring for intra-operative findings and histopathology reports, APACHE-Ⅱ can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy. However, for audit purposes,either of the two scoring systems can be used.

Sepsis associated delirium mimicking postoperative delirium as the initial presenting symptom of urosepsis in a patient who underwent nephrolithotomy

We report a case of 70 years old male who underwent percutaneous nephrolithotomy for renal calculi.After an uneventful recovery from anaesthesia,the patient developed delirium which manifested as restlessness,agitation,irritability and combative behavior.All other clinical parameters including arterial blood gas,chest X-ray and core temperature were normal and the patient remained haemodynamically stable.But 45 min later the patient developed florid manifestations of septic shock.He was aggressively managed in a protocolized manner as per the Surviving Sepsis Guidelines in the Critical Care Unit and recovered completely.There are no case reports showing postoperative delirium as the only initial presentation of severe sepsis,with other clinical parameters remaining normal.Both urosepsis and sepsis associated delirium have very high mortality.High index of suspicion and a protocolized approach in the management of sepsis can save lives.

Update on the aetiopathogenesis of obstructive sleep apnea:Role of inflammatory and immune mediated mechanisms

Obstructive sleep apnea(OSA)is often a lifestyle disease associated with obesity,which is rapidly evolving as a major health concern with diverse multisystemic implications.To prevent and mitigate its adverse effects and reduce its burden on society,its aetiopathogeneses must be precisely understood.Numerous studies focusing on the range of diverse anatomic,functional,and lifestyle factors have already been carried out to determine the possible contributory roles of these factors in OSA.Recently,evidence to validate the role of inflammatory pathways and immune mechanisms in the aetiopathogeneses of OSA is being developed.This allows for further research and translation of such knowledge for targeted therapeutic and preventive interventions in patients with or who are at risk of developing OSA.