Endovascular revascularization of critical limb ischemia: the role of ultrasound-guided popliteal sciatic nerve block for the procedural pain management.

OBJECTIVES: To evaluate the impact of the ultrasound-guided popliteal sciatic nerve block (PSNB) for pain management during endovascular treatment of chronic limb-threatening ischemia (CLTI). MATERIAL AND METHODS: From November 2020 to January 2022, 111 CLTI patients that underwent endovascular procedures were prospectively enrolled in this prospective single-arm interventional study. Ultrasound-guided PSNB was used for procedural pain control. Pain intensity was evaluated throughout the procedure (baseline, 10 min after the block, pain peak, and at the end of the procedure) with the visual analog scale (VAS). RESULTS: Forty-six patients underwent above-the-knee revascularization (ATK), 20/111 below-the-knee (BTK) revascularization, 20/111 to both ATK and BTK revascularization. In 25 cases, no endovascular option was feasible at diagnostic angiography. The PSNB was effective in 96% of patients, with no need for further pain management with a statistically significant reduction (p < 0.0001) in the mean value of the VAS from 7.86 ± 1.81 (pre-procedural) to 2.04 ± 2.20 after 10 min from the block and up to 0.74 ± 1.43 at the end of the procedure (mean time 43 min). Only 1 complication related to the popliteal sciatic nerve block was registered (a temporary foot drop, completely resolved within 48 h). The time necessary to perform the block ranged between 4 and 10 min. CONCLUSION: Ultrasound-guided PSNB is a feasible and effective method to manage patients with rest pain and increase comfort and compliance during endovascular procedures. CLINICAL RELEVANCE STATEMENT: An ultrasound-guided popliteal sciatic nerve block is a safe, feasible, and effective technique to manage pain during endovascular treatment of chronic limb-threatening ischemia, especially in frail patients with multiple comorbidities who are poor candidates for deep sedoanalgesia or general anesthesia. KEY POINTS: Endovascular treatment of CTLI may require long revascularization sessions in patients with high levels of pain at rest, which could be exacerbated during the revascularization procedure. The PSNB is routinely used for anesthesia and analgesia during foot and ankle surgery, but the experience with lower limb revascularization procedures is very limited and not included in any international guideline. Ultrasound-guided PSNB is a feasible and effective regional anesthesia technique to relieve procedural and resting pain. Because of its safety and availability, every interventional radiologist should know how to perform this type of loco-regional anesthesia.

The role of time interval elimination on pain control of preterm infants by sucrose administration.

PURPOSE: The 2-min time interval of sucrose administration given before minor painful procedures in preterm infants is based on a few limited studies. We aimed to assess availability of sucrose analgesia in emergency states of minor procedural pain by eliminating the 2-min time interval prior to heel lance in preterm infants. The primary outcome was Premature Infants Pain Profile-Revised (PIPP-R) at 30 and 60 s. METHODS: Healthy 69 preterms undergoing a heel lance, who were assigned randomly to 1 of 2 groups, i.e., group I, with the 2-min time interval of per oral 24% sucrose given prior to heel lance, or group II, without a time interval of per oral 24% sucrose, were recruited. Premature Infants Pain Profile-Revised, crying incidence, duration, and heart rate at 30 and 60 s following heel lance were the outcome measures in this single-center, randomized, prospective study. RESULTS: The 2 groups did not differ significantly in PIPP-R scores at 30 s (6.63 vs. 6.32, p = .578) and 60 s (5.80 vs. 5.38, p = .478). The crying incidence was similar between the 2 groups (p = .276). The median crying duration was 6 s (range: 1-13 s) in group I and 4.5 s (range: 1-18 s) in group II (p = .226). No significant differences in the heart rates between the 2 groups and the proportion of adverse events by time interval elimination were recorded. CONCLUSIONS: Eliminating the time interval did not decrease the analgesic effect of orally administered 24% sucrose given prior to heel lance. In emergency states of minor procedural pain, eliminating the 2-min time interval following sucrose administration is safe and efficacious in preterm infants.

Effectiveness of fentanyl pectin nasal citrate in controlling episodes of breakthrough cancer pain triggered by routine radiotherapy procedures.

PURPOSE: The aim of the study was to evaluate the effectiveness of fentanyl pectin nasal spray (FPNS) in controlling procedural breakthrough cancer pain (BTCP) in advanced cancer patients undergoing radiotherapy. MATERIALS AND METHODS: This study involved 62 advanced cancer patients, with well-controlled background pain, who presented BTCP associated to routine radiotherapy procedures, treated with FPNS according to our protocol of administration. The BPE intensity was measured using a visual analog scale (VAS). RESULTS: The BTCP was triggered during the computed tomography simulation (79.3%) or treatment delivery (20.7%). Patients indicated a mean VAS of 8.8 (range 7-10) when attempting the procedure. After 4.5 min (range 2-10) of the first FPNS dose, the majority of patients (85.5%) indicated a VAS of 4.3 (range 2-6). 15.5% of the patients did not respond after 15 min; requiring a second dose. All these patients responded, reporting a mean VAS of 4.2 (range 4-6) after 3.0 min (range 2-5) of the second dose. None of the patients required a third dose, nor reported an AE after the administration of FPNS. CONCLUSIONS: In our knowledge, our study is the one of highest recruitment, and with the fastest response of BTCP treated with FPNS reported in advanced cancer patients undergoing radiotherapy. FPNS has proven to be highly effective in reducing the intensity of procedural BTCP in a very short period of time.

Early Procedural Pain Is Associated with Regionally-Specific Alterations in Thalamic Development in Preterm Neonates.

Very preterm human neonates are exposed to numerous invasive procedures as part of life-saving care. Evidence suggests that repetitive neonatal procedural pain precedes long-term alterations in brain development. However, to date the link between pain and brain development has limited temporal and anatomic specificity. We hypothesized that early exposure to painful stimuli during a period of rapid brain development, before pain modulatory systems reach maturity, will predict pronounced changes in thalamic development, and thereby cognitive and motor function. In a prospective cohort study, 155 very preterm neonates (82 males, 73 females) born 24-32 weeks' gestation underwent two MRIs at median postmenstrual ages 32 and 40 weeks that included structural, metabolic, and diffusion imaging. Detailed day-by-day clinical data were collected. Cognitive and motor abilities were assessed at 3 years, corrected age. The association of early (skin breaks, birth-Scan 1) and late pain (skin breaks, Scans 1-2) with thalamic volumes and N-acetylaspartate (NAA)/choline (Cho), and fractional anisotropy of white-matter pathways was assessed. Early pain was associated with slower thalamic macrostructural growth, most pronounced in extremely premature neonates. Deformation-based morphometry analyses confirmed early pain-related volume losses were localized to somatosensory regions. In extremely preterm neonates early pain was associated with decreased thalamic NAA/Cho and microstructural alterations in thalamocortical pathways. Thalamic growth was in turn related to cognitive and motor outcomes. We observed regionally-specific alterations in the lateral thalamus and thalamocortical pathways in extremely preterm neonates exposed to more procedural pain. Findings suggest a sensitive period leading to lasting alterations in somatosensory-system development.SIGNIFICANCE STATEMENT Early exposure to repetitive procedural pain in very preterm neonates may disrupt the development of regions involved in somatosensory processing, leading to poor functional outcomes. We demonstrate that early pain is associated with thalamic volume loss in the territory of the somatosensory thalamus and is accompanied by disruptions thalamic metabolic growth and thalamocortical pathway maturation, particularly in extremely preterm neonates. Thalamic growth was associated with cognitive and motor outcome at 3 years corrected age. Findings provide evidence for a developmentally sensitive period whereby subcortical structures in young neonates may be most vulnerable to procedural pain. Furthermore, results suggest that the thalamus may play a key role underlying the association between neonatal pain and poor neurodevelopmental outcomes in these high-risk neonates.

Distraction Kits for Pain Management of Children Undergoing Painful Procedures in the Emergency Department: A Pilot Study.

To assess the feasibility, usefulness, and acceptability of using distraction kits, tailored to age, for procedural pain management of young children visiting the emergency department and requiring a needle-related procedure. A pre-experimental design was piloted. A kit, tailored to age (infants-toddlers: 3 months-2 years; preschoolers: 3-5 years), was provided to parents before their child's needle-related procedure. Data was collected to assess feasibility, usefulness, and acceptability of the kits by parents and nurses. Pain was measured pre-, peri-, and postprocedure using the Face, Legs, Activity, Cry, Consolability scale. A total of 25 infants and toddlers (mean age: 1.4 ± .7 years) and 25 preschoolers (mean age: 4.0 ± .9) participated in the study. Parents and nurses considered the kits useful and acceptable for distraction in the emergency department, especially in the postprocedural period. Addition of more animated and interactive toys to the kits was suggested. In the infants-toddlers group, mean pain scores were 1.6 ± 2.5 preprocedure, 7.1 ± 3.0 periprocedure, and 2.5 ± 2.5 postprocedure. In the preschoolers group, mean pain scores were 1.6 ± 3.0 preprocedure, 4.8 ± 3.4 periprocedure, and 2.0 ± 3.2 postprocedure. Distraction kits were deemed useful and acceptable by parents and emergency nurses. They are an interesting nonpharmacologic option for nurses to distract children, giving them a sense of control over their pain and improving their hospital experience. Future research should address the feasibility of distraction kits for a broader population of patients and a variety of painful procedures.

Preterm newborn pain research review.

This narrative review is based on a literature search of PubMed and PsycINFO for research on preterm newborn pain published during the last ten years. The high prevalence of painful procedures being performed with preterm newborns without analgesia (79%), with a median of 75 painful procedures being received during hospitalization and as many as 51 painful procedures per day highlights the importance of this problem. This review covers the pain assessments that have been developed, the short-term effects of the painful procedures, the longer-term developmental outcomes and the pharmacological and alternative therapies that have been researched. The most immediate effects reported for repeated painful procedures include increased heart rate, oxidative stress and cortisol as well as decreased vagal activity. Lower body weight and head circumference have been noted at 32 weeks gestation. Blunted cortisol reactivity to stressors has been reported for three-month-olds and thinner gray matter in 21 of 66 cerebral regions and motor and cognitive developmental delays have been noted as early as eight months. Longer-term outcomes have been reported at school age including less cortical thickness, lower vagal activity, delayed visual- perceptual development, lower IQs and internalizing behavior. Pharmacological interventions and their side effects and non-pharmacological therapies are also reviewed including sucrose, milk and nonnutritive sucking which have been effective but thought to negatively affect breast-feeding. Full-body interventions have included tucking, swaddling, kangaroo care and massage therapy. Although these have been effective for alleviating immediate pain during invasive procedures, research is lacking on the routine use of these therapies for reducing long-term pain effects. Further, additional randomized controlled replication studies are needed.