The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP).

BACKGROUND: Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES: In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS: The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS: There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION: These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments.

Comprehensive, evidence-based, consensus guidelines for prescription of opioids for chronic non-cancer pain from the American Society of Interventional Pain Physicians (ASIPP)

Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting for perioperative management. These patients are either on buprenorphine or methadone for the maintenance and treatment of opioid addiction or chronic pain. In the settings of acute pain, the optimal management of patients with opioid use disorder is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents. The purpose of this narrative review is to summarize the existing studies on the perioperative management of patients who are using buprenorphine and methadone and provide guidance for the management of patients with opioid use disorder during the perioperative period.

Unilateral Bilevel Erector Spinae Plane Catheters for Flail Chest: A Case Report.

Providing effective analgesia for acute rib fractures is crucial in avoiding pulmonary complications. Erector spinae plane (ESP) block is an alternative treatment option to neuraxial techniques. ESP blocks have demonstrated pain relief in patients with rib fractures. However, the utilization of unilateral bilevel ESP catheters has not been described. We present a case of unilateral bilevel ESP catheters placed in a patient with flail chest secondary to a motor vehicle accident.

Sacroiliac Joint Pain in Pregnancy: A Case Report.

Sacroiliac joint pain is one of the most common causes of low back pain in pregnant women. We present a case of a 30-year-old G2P1 at 20 weeks gestation presenting with intractable low back pain refractory to conservative management. History and physical examination revealed sacroiliac joint as the pain generator. We elected to do an ultrasound-guided sacroiliac joint injection that significantly abated her pain. This article aims to review the diagnosis, pathophysiology, and treatment approaches to adequately manage sacroiliac joint pain in pregnant women.

Early Prediction of Prognosis in Elderly Acute Stroke Patients.

Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. DESIGN: Retrospective observational cohort study. SETTING: Academic comprehensive stroke center. PATIENTS: Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27. CONCLUSIONS: Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.

Sevoflurane and renal function: a meta-analysis of randomized trials.

OBJECTIVE: This study aims to describe the overall cumulative effect of sevoflurane on kidney function in healthy patients in terms of mean plasma creatinine, blood urea nitrogen (BUN), creatinine clearance, urinary protein, and glucose excretion at 24 and 72 hours post-anesthesia. DATA RETRIEVAL: A systematic literature search using MEDLINE and EMBASE as primary search engines was conducted. Articles, relevant abstracts, and citations dated January 1, 1995 to June 30, 2016 were retrieved. DATA SELECTION: Search terms included the pharmacological generic name sevoflurane. Search was expanded using the terms "renal function" OR "kidney" function AND "creatinine" OR "blood urea nitrogen" OR "creatinine clearance" OR "proteinuria" OR "glucosuria" OR "nephrotoxicity." Limitations included randomized controlled trial, humans, and ages 19 and above, to include English and non-English text formats. All bibliographic indices for the relevant journals identified were also searched and collated according to relevance. MAIN OUTCOME MEASURES: Changes in serum/plasma creatinine, BUN, urinary protein, and glucose excretion of sevoflurane at 24 and 72-hours were determined. RESULTS: Six relevant studies were qualified by both the inclusion criteria and inclusion dates. This review consists of 873 patients, 65% are males and 35% are females, with mean age of 56 ± 3 years. Sevoflurane was compared to isoflurane with regard to its nephrotoxic potential. Analyses on the effects of sevoflurane were performed on serum/plasma creatinine, BUN, urinary protein, and glucose excretion at 24 and 72 hours which showed no statistical difference between sevoflurane and isoflurane. CONCLUSION: In an apparently healthy adult without coexisting renal disorder, sevoflurane does not produce elevations in creatinine and BUN above the established upper limit of the reference range.

Red Cell Storage Duration Does Not Affect Outcome after Massive Blood Transfusion in Trauma and Nontrauma Patients: A Retrospective Analysis of 305 Patients.

BACKGROUND: Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. METHODS: We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. RESULTS: 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. CONCLUSIONS: Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.

A comparison of renal responses to sevoflurane and isoflurane in patients undergoing donor nephrectomy: a randomized controlled trial.

Sevoflurane and isoflurane are volatile halogenated ether widely used in anesthesia. Both have comparable potency and easy titratability but sevoflurane has lower pungency and results in faster patient recovery. Isoflurane, however, is more affordable. The nephrotoxicity of sevoflurane is undisputed but studies on isoflurane nephrotoxicity are lacking. The objective of this paper is to determine the overall nephrotoxicity profile of sevoflurane and isoflurane in donor nephrectomy patients using the renal function markers - nuclear glomerular filtration rate (GFR), serum creatinine, urine protein-to-creatinine ratio, proteinuria, and glucosuria. A randomized comparative study of postoperative renal functions in donor nephrectomy patients who had received either low-flow (< 1 L/min) sevoflurane or isoflurane were analyzed. The renal parameters were repeated 72 hours post anesthesia. Forty-seven subjects (46%) were randomized to receive isoflurane while fifty-five received sevoflurane (54%). Between the two anesthetic groups, there was no significant difference in terms of serum creatinine, total GFR, or nuclear GFR. There was a statistically higher proportion of patients with urine protein-to-creatinine ratios of 0.2 and above in the isoflurane group (64% vs. 38%), while more patients in the sevoflurane group had ratios above 0.2 (62% vs. 36%, P < 0.05). The type of anesthetic agent was not an independent predictor of increasing serum creatinine, total GFR and urine protein-to-creatinine ratio and nuclear GFR. In conclusion, the overall nephrotoxicity profile of sevoflurane and isoflurane-treated donor nephrectomy patients is minimal.

Bipolar Radiofrequency Neurotomy to Treat Neck and Back Pain in Patients with Automatic Implantable Cardioverter Defibrillator.

We report 2 cases of successful treatment of neck and back pain with bipolar radiofrequency ablation (RFA) of the cervical and lumbar facet joints in patients with an automatic implantable cardioverter defibrillator (AICD).Two patients with complex cardiac histories and AICD devices were treated with bipolar RFA of the facet joints. One presented with axial neck pain and the other with axial back pain. The histories and physical examinations were consistent with facetogenic pain. Diagnostic medial branch block resulted in more than 70% pain relief lasting for several days, allowing patients to perform routine daily activities without significant pain. However, we were concerned about the use of conventional RFA of the medial branches of nerves for the fear of interference with the function of AICD by the RF currents and energy. We took advantage of the localized and limited current of bipolar RFA to perform this procedure for the cervical or lumbar facet joints avoiding any interference with the function of AICD. The procedures provided long-term pain relief to the patients, and marked improvement in their functional status without any evident complications related to the function of their AICD.This case report describes the safe and successful completion of bipolar RFA of the medial branch nerves to treat cervical and lumbar facetogenic pain in patients with AICD. This modality of treatment may be considered in patients with AICD. We are finding it to be increasingly common that patients who present with chronic neck and back pain have AICDs in place.

Teaching basic lung isolation skills on human anatomy simulator: attainment and retention of lung isolation skills.

BACKGROUND: Lung isolation skills, such as correct insertion of double lumen endobronchial tube and bronchial blocker, are essential in anesthesia training; however, how to teach novices these skills is underexplored. Our aims were to determine (1) if novices can be trained to a basic proficiency level of lung isolation skills, (2) whether video-didactic and simulation-based trainings are comparable in teaching lung isolation basic skills, and (3) whether novice learners' lung isolation skills decay over time without practice. METHODS: First, five board certified anesthesiologist with experience of more than 100 successful lung isolations were tested on Human Airway Anatomy Simulator (HAAS) to establish Expert proficiency skill level. Thirty senior medical students, who were naive to bronchoscopy and lung isolation techniques (Novice) were randomized to video-didactic and simulation-based trainings to learn lung isolation skills. Before and after training, Novices' performances were scored for correct placement using pass/fail scoring and a 5-point Global Rating Scale (GRS); and time of insertion was recorded. Fourteen novices were retested 2 months later to assess skill decay. RESULTS: Experts' and novices' double lumen endobronchial tube and bronchial blocker passing rates showed similar success rates after training (P >0.99). There were no differences between the video-didactic and simulation-based methods. Novices' time of insertion decayed within 2 months without practice. CONCLUSION: Novices could be trained to basic skill proficiency level of lung isolation. Video-didactic and simulation-based methods we utilized were found equally successful in training novices for lung isolation skills. Acquired skills partially decayed without practice.

Teaching basic fiberoptic intubation skills in a simulator: initial learning and skills decay.

PURPOSE: Generally, novices are taught fiberoptic intubation on patients by attending anesthesiologists; however, this approach raises patient safety concerns. Patient safety should improve if novice learners are trained for basic skills on simulators. In this educational study, we assessed the time and number of attempts required to train novices in fiberoptic bronchoscopy and fiberoptic intubation on simulators. Because decay in skills is inevitable, we also assessed fiberoptic bronchoscopy and fiberoptic intubation skill decay and the amount of effort required to regain fiberoptic bronchoscopy skill. METHODS: First, we established attempt- and duration-based quantitative norms for reaching skill proficiency for fiberoptic bronchoscopy and fiberoptic intubation by experienced anesthesiologists (n = 8) and prepared an 11-step checklist and a 5-point global rating scale for assessment. Novice learners (n = 15) were trained to reach the established skill proficiency in a Virtual Reality simulator for fiberoptic bronchoscopy skills and a Human Airway Anatomy Simulator for fiberoptic intubation skills. Two months later, novices were reassessed to determine decay in learned skills and the required time to retrain them to fiberoptic bronchoscopy proficiency level. RESULTS: Proficiency in fiberoptic bronchoscopy skill level was achieved with 11 ± 5 attempts and after 658 ± 351 s. After 2 months without practice, the time taken by the novices to successful fiberoptic bronchoscopy on the Virtual Reality simulator increased from 41 ± 8 to 68 ± 31 s (P = 0.0138). Time and attempts required to retrain them were 424 ± 230 s and 9.1 ± 4.6 attempts, respectively. CONCLUSION: Novices were successfully trained to proficiency skill level. Although fiberoptic bronchoscopy skills started to decay within 2 months, the re-training time was shorter.

Right-Sided Pleural Effusion in a Critically Ill Stroke Patient.

Pleural fluid collections are common in those critically ill. We report the case of a left middle cerebral artery stroke patient who developed respiratory distress and required intubation and mechanical ventilation. Although the patient's clinical status and oxygenation improved, there was persistence of right-sided opacity in the chest radiograph. Further workup proved a right-sided pleural effusion, which was drained and managed. Following extubation, a swallow study was ordered, which led to a fluoroscopic examination that demonstrated esophageal perforation. Thoracic surgery was consulted and did a primary repair of perforation and noted non-small cell carcinoma on the perforated site.

Hypercapnia: is it protective in lung injury?

Hypercapnic acidosis has been regarded as a tolerated side effect of protective lung ventilation strategies. Various in vivo and ex vivo animal studies have shown beneficial effects in acute lung injury setting, but some recent work raised concerns about its anti-inflammatory properties. This mini-review article aims to expand the potential clinical spectrum of hypercapnic acidosis in critically ill patients with lung injury. Despite the proven benefits of hypercapnic acidosis, further safety studies including dose-effect, level-and-onset of anti-inflammatory effect, and safe applicability period need to be performed in various models of lung injury in animals and humans to further elucidate its protective role.

Hypercapnia and ventilator-induced diaphragmatic dysfunction.

In the previous issue of Critical Care, Jung and colleagues report on the preventive effects of hypercapnia on ventilator-induced diaphragmatic dysfunction (VIDD) under controlled ventilation. Possibly, a combination of controlled hypercapnia and allowed spontaneous breathing efforts may provide complementary protection for diaphragm and respiratory functionality during mechanical ventilation. However, further safety and efficacy studies need to be performed in various different animal models and patients before a universal application of hypercapnia in the critical care setting for the prevention of VIDD can be considered.