Anaesthesia & Intensive Care Medicine

The role of regional anaesthesia in the management of acute pain Publication date: Available online 4 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Philip Hassell, James Stimpson Abstract The role of regional anaesthesia in anaesthetic practice has become essential to enhance acute pain control, minimize the use of systemic opioids and optimize the multidisciplinary approach to enhanced recovery programmes. They are used as powerful tools to enable ambulatory surgery in a wide variety of surgical specialties and reduce the transition from acute to chronic pain. Adjuncts to local anaesthetics can be used to prolong block time and target nociception specifically allowing motor function to remain.

Assessment of acute and chronic pain Publication date: Available online 4 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Tim McCormick, Claire Frampton Abstract Acute and chronic pain states overlap in chronology and pathophysiology but both can remain under-managed. Assessment aims to elucidate underlying diagnosis and/or pain generators that can then guide treatment strategies. Assessment should be repeated to assess efficacy of treatments and the presence of side effects. Self-report questionnaires are available to assist in diagnosis and monitoring of pain and its related dimensions but they do not replace a thorough assessment by an experienced clinician.

Opioid mechanisms and opioid drugs Publication date: Available online 3 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Helen Laycock, Carston Bantel Abstract Opioids are effective in acute and cancer pain management and have increasingly been prescribed in chronic non-cancer pain despite concerns regarding long-term use and lack of efficacy. Opioid actions are via G protein coupled receptors, the activation of which leads to a variety of physiological consequences including analgesia. Prescribing opioids requires careful consideration of individual drug pharmacokinetics and pharmacodynamics, their actions across different physiological systems, side effect profiles and patient factors that influence the drug efficacy to ensure the best opioid is prescribed for each patient.

The neurobiology of chronic pain states Publication date: Available online 3 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Anthony H. Dickenson Abstract Plasticity enables alterations in transmission in nociceptive systems. It is this plasticity in the nervous system that can alter the linear relation between noxious stimuli and the perception of pain and is important in the switch from acute to chronic pain. In this way, a number of CNS mechanisms can alter neuronal activity, leading to abnormal ongoing and stimulus-evoked pains due to peripheral and central changes. Peripheral nerves can become sensitized, spinal cord neurons can be rendered hyperexcitable and ascending projections to higher centres can further trigger changes in descending controls from the midbrain and brainstem. Together, these changes, all of which appear to involve reversible physiological and pharmacological plasticity, can alter the relationship between an applied stimulus and the perceived response and so lead to persistent pain states.

The role of occupational therapy in enabling people with chronic pain to return to work or education Publication date: Available online 3 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Wendy Hill, Michelle Macartney Abstract Occupational therapy is based on the premise that there is an intrinsic relationship between occupations, health and wellbeing. Chronic pain restricts the performance of activities that individuals need to, want to and are expected to perform, including working or studying. Young people who have a chronic pain condition may be restricted in their participation with school or higher education which can result in them being disadvantaged regarding their future potential for employment. Work is central to most adults’ occupational identity and is therefore a key focus for occupational therapy intervention. In addition to the strategies used generally with patients, such as activity management, activity adaptation and the development of coping strategies, occupational therapy with young people and adults who want to access work and/or education will address the biological, social and psychological barriers to returning or remaining at school or work. The aim of this article is to explain the role and value of occupational therapy within the pain management team in relation to enabling patients return or remain in work or education.

The use of atypical analgesics by intravenous infusion for acute pain: evidence base for lidocaine, ketamine and magnesium Publication date: Available online 3 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): David Hutchins, Mark Rockett Abstract Atypical analgesics include antiepileptics and other membrane stabilizers (lidocaine and mexilitine), antidepressants, alpha-2-noradrenergic agonists, N-methyl-d-aspartate (NMDA) antagonists, corticosteroids and cannabinoids. This review will focus on three drugs commonly infused as intravenous co-analgesics. We will review the theoretical mechanisms of action, efficacy and clinical effectiveness of lidocaine, ketamine and magnesium. The evidence base supporting their use has expanded in recent years and is discussed below.

Anatomy, physiology and pharmacology of pain Publication date: Available online 3 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Michael J. Hudspith Abstract Pain is neither a mere sensation nor a simple warning of potential or actual bodily injury: rather it a complex emotional experience arising from integrated processing of nociceptive input subject to inhibitory and excitatory modulatory influences at multiple levels of the neuroaxis. Transmembrane protein ion-channels transduce mechanical, thermal and chemical tissue injury into electrophysiological signals that are transmitted to supraspinal structures via multiple synapses that exhibit neuroplasticity dependent upon coincident neuronal and immune cell interactions. There are therefore multiple potential pharmacological targets and the complexity of pain perception necessitates multimodal management.

The genesis of chronic pain Publication date: Available online 2 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Bharti Seth, Lorraine de Gray Abstract The theories behind the evolution of the genesis of chronic pain are explored from a historical perspective. The major focus of the article explores the biomedical and the psychosocial factors that contribute to the genesis of chronic pain in particular how the physical and psychological interact together. Risk factors and pre-existing determinants are discussed.

Techniques of opioid administration Publication date: Available online 2 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Christopher JG. Green, Somnath Bagchi Abstract Opiates remain the mainstay of the management of severe pain in acute, chronic and palliative settings across all population ages. Pharmacological advancement allows alternative routes of drug delivery best suited to individual patients and their conditions, with improved efficacy and safety. The different approaches to administration vary in their convenience, both to staff and patients, which can translate to differences in prescription compliance. Furthermore, the choice of technique can reduce the amount of drug administered, thereby improving the side effect profile. All opiates, regardless of the technique employed, require meticulous and careful titration based upon sound understanding. Training of staff and education of patients regarding the logistics of the chosen route is important to ensure optimal opiate delivery and detection of undesirable adverse events. Abuse and diversion of opiates warrants judicious administration and prescription considerations.

The role of physiotherapy in the management of chronic pain Publication date: Available online 2 July 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Judith Semmons Abstract The role of physiotherapy in managing chronic pain is challenging. A multidisciplinary approach incorporating several specialities within the pain clinic is recommended. Treatment primarily focuses on the biopsychosocial model: part of the clinician's skill is to decide which part or parts of this biopsychosocial model influence the patient's pain. Key physiotherapy treatments are described: education, patient empowerment and promoting exercise and function. Patients often fear exercise as without appropriate guidance their pain tends to increase so they believe it may be harmful. Patients are advised not to push through pain which may cause ‘wind up’ and increased pain. Phased activities and goal setting are discussed. More specific or individual treatments are described such as cognitive functional therapy, desensitization and mirror therapy.