Ganglionic Local Opioid Analgesia at the Superior Cervical Ganglion: MRI-Verified Solution Spread.

INTRODUCTION: Ganglionic local opioid analgesia (GLOA) at the superior cervical ganglion (SCG) is performed for pain control and is known to be an effective procedure. In this study, we evaluated the spread of the injectate in the area of the SCG. Our expectation was that there would be a correlation between the area and volume of the injectate spread and post-procedural outcome measures. METHODS: This was a retrospective blinded review of magnetic resonance imaging (MRI) scans. Assessors evaluated the anatomical area of fluid spread, the furthermost spread from midline, any hampered spread and contact of contrast fluid with other structures. The efficacy of GLOA and complications were estimated. RESULTS: The main solution spread reached from the C1 to C3 vertebrae. The furthest spread in the lateral and sagittal planes was 21.2 and 15.2 mm, respectively. The furthest craniocaudal spread was 63.5 mm. In 53.3% and 33% of interventions, the solution was found in the parapharyngeal space and in its "medial compartment," respectively. A correlation was found between pain relief and both solution spread and volume of solution spread. No hampered spread was recorded. A negative correlation between pain reduction and number of GLOA was observed. Higher pre-procedural pain intensity was correlated with higher pain reduction. We estimated pain relief in 93% of procedures correctly. No correlation between post-procedural Numerical Rating Scale (NRS) scores and different needle approaches was found. CONCLUSION: For the transoral blocking technique, a strict laterodorsal needle direction is recommended to prevent possible block failures. A total volume of 2 ml injected into the parapharyngeal space and its "medial compartment" is recommended. Higher volumes may lead to uncontrolled distribution patterns. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT05257655; date of registration 2022-02-25; patient enrollment date from 2023-01-09 to 2023-08-31.

The injection of low-dose opioids (mainly buprenorphine or sufentanil) to different sympathetic ganglia has been termed "ganglionic local opioid analgesia" (GLOA). This form of therapy has been successfully used for numerous, often protracted diseases that severely impair the patient's quality of life, such as trigeminal neuralgia. For example, as part of a multimodal approach for pain management, GLOA at the superior cervical ganglion should be considered for pain treatment in patients suffering from trigeminal neuralgia with high pre-procedural pain scores.

[Clinical efficacy of auricular vagus nerve stimulation in the treatment of chronic and acute pain : A systematic review]. / Klinische Wirksamkeit der aurikulären Vagusnervstimulation in der Behandlung chronischer und akuter Schmerzen : Eine systematische Übersichtsarbeit.

BACKGROUND: Current guidelines recommend a personalized, multimodal, and interdisciplinary approach for the treatment of chronic pain. Already in the acute treatment of postoperative pain, it can be useful to minimize risk factors for chronification. Auricular vagus nerve stimulation (aVNS) could be an effective non-drug therapy for the treatment of chronic and acute pain. AIM OF THE WORK: The aim of this systematic review is to evaluate the clinical efficacy of aVNS in chronic and acute pain as well as its effect on medication intake. MATERIALS AND METHODS: A systematic literature search was carried out on the application of auricular electrical stimulation in chronic and acute pain. Studies were classified according to their level of evidence and evaluated via the Jadad scale as well as their scientific validity, and then analyzed in terms of indication, method, stimulation parameters, duration of treatment, efficacy, and safety. RESULTS: Twenty studies on chronic pain indications, ten studies on acute postoperative pain, as well as seven studies on experimental acute pain were identified and analyzed. The search revealed a total of n = 1105 aVNS-treated patients. The best evidence on the efficacy of aVNS is available for the indications chronic low back pain, chronic cervical syndrome, chronic abdominal pain, and chronic migraine as well as acute postoperative pain in oocyte aspiration, laparoscopic nephrectomy, and open colorectal surgery. Additionally a significant reduction in analgesic or opiate intake was evident in most studies. In three randomized controlled trials in chronic pain patients, a sustainable pain reduction over a period of up to 12 months was shown. Overall, aVNS was very well tolerated. CONCLUSION: This review indicates that aVNS can be a complementary and effective non-drug treatment for patients with chronic and acute postoperative pain. Future studies in these indications should focus on standardizing and optimizing treatment parameters, inclusion of quality-of-life outcome parameters, and longer follow-up periods to better understand the sustainable therapeutic effect of aVNS.

Pain in Austrian hospitals: evaluation of 1089 in-patients.

BACKGROUND: Despite the existence of internationally consistent guidelines for the management of pain, efficient regional anesthesia techniques, safe pain medications, and organizational structures, e.g., acute pain services, various studies have shown that pain is still common among both surgical and non-surgical in-patients. OBJECTIVE: The primary objective of this study was to evaluate, on a multi-center basis, the point pain prevalence of surgical and non-surgical in-patients. We further analyzed pain intensities, in-hospital pain triggers, pain-related impairments, pain assessments, patient information about pain, and patient satisfaction with pain therapy. This benchmark information should lead to better implementation of pain management strategies and thus improve health care quality. METHODS: We surveyed all adult in-patients in three general hospitals in Austria (general hospital Klagenfurt am Wörthersee, general hospital Villach, general hospital Wolfsberg) on the index day with two standardized questionnaires for both surgical and non-surgical patients. RESULTS: Overall, a pain prevalence of 40.0%, with no statistically significant difference between surgical and non-surgical patients, was shown. Higher pain prevalence in female patients, high pain prevalence in the age group 18-30 years, and highest pain prevalence in the age group over 90 years old was found. Overall pain intensity was relatively low, but unacceptable maximum pain within the preceding 24 h was shown. Different in-hospital pain triggers like patient's care and mobilization were found. Our survey has shown that pain has an impact on personal hygiene, mobilization, mood, sleep, and appetite. However, patients were very satisfied with their pain therapy. CONCLUSION: Medical staff and nurses have to be sensitized to the urgent need to improve pain management strategies.

Computed Tomography-Guided Coeliac Plexus Neurolysis in Palliative in-Patients with Intra-Abdominal Malignancy: Retrospective Evaluation of Neurolytic Solution Spread as a Predictive Factor.

INTRODUCTION: Computed tomography (CT)-guided coeliac plexus neurolysis (CPN) is considered effective at controlling pain in patients with intra-abdominal malignancies. The primary objective was to correlate pain outcomes with the spread of neurolytic solution in the coeliac area and to evaluate the predictive value for the spread of injectate for pain outcomes and side effects. METHODS: Blinded CT scans were reviewed. The coeliac area was divided into nine quadrants. Assessors evaluated quadrants according to contrast spread, needle tip position, and the contact between the injectate and other organs and plexuses. Efficacy of CPN and complications were estimated. RESULTS: In 54.9% there was complete spread of the neurolytic in the coeliac area with no correlation between pain relief and spread of injectate. In 85% the neurolytic had contact with viscera with no correlation with pain relief or complications. There was no correlation between needle tip position and spread of the neurolytic and contact of the neurolytic with viscera. In 71.6% the injectate was found to have spread into "other" plexuses. In 13.3% hampered spread of the injectate was observed. There was no correlation between patterns of injectate spread and pain relief, pain relief and spread of injectate in any particular quadrants, and expected and documented post-procedural pain scores. CONCLUSIONS: Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

CT-guided coeliac plexus neurolysis is considered effective at controlling pain in patients with intra-abdominal malignancies. Based on the spread of contrast medium clinicians can neither correctly anticipate the pain relief or post-procedural NRS, nor the duration of pain relief and complications. It is not essential to have the perfect sickle-shaped spread of the injectate for adequate pain control.

CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients.

INTRODUCTION: Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN. METHODS: Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled. RESULTS: A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes. CONCLUSIONS: In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.

In patients with intra-abdominal malignancy-related abdominal pain, CT-guided coeliac plexus neurolysis is a safe and effective procedure. It can provide long-lasting significant relief of background pain and breakthrough cancer pain. As part of a multimodal approach, coeliac plexus neurolysis should be considered as an earlier option for pain management in patients with intractable abdominal cancer pain.

SARS-CoV-2: recommendations for treatment in intensive care medicine.

Coronavirus disease 2019 (COVID-19) progresses mildly in most of the cases; however, about 5% of the patients develop a severe acute respiratory distress syndrome (ARDS). Of all COVID-19 patients 3% need intensive care treatment, which becomes a great challenge for anesthesiology and intensive care medicine, medically, hygienically and for technical safety requirements. For these reasons, only experienced medical and nursing staff in the smallest grouping possible should be assigned. For these team members, a consistent use of personal protective equipment (PPE) is essential.Due to the immense medical challenges, the following treatment guidelines were developed by the ÖGARI (Österreichische Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin), FASIM (Federation of Austrian Societies of Intensive Care Medicine) and ÖGIAIN (Österreichische Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin).The recommendations given in this article are to be understood as short snapshots of the moment; all basic guidelines are works in progress and will be regularly updated as evidence levels, new study results and additional experience are gathered.

Vitamin D deficiency 2.0: an update on the current status worldwide.

Vitamin D testing and the use of vitamin D supplements have increased substantially in recent years. Currently, the role of vitamin D supplementation, and the optimal vitamin D dose and status, is a subject of debate, because large interventional studies have been unable to show a clear benefit (in mostly vitamin D replete populations). This may be attributed to limitations in trial design, as most studies did not meet the basic requirements of a nutrient intervention study, including vitamin D-replete populations, too small sample sizes, and inconsistent intervention methods regarding dose and metabolites. Vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 50 nmol/L or 20 ng/ml) is associated with unfavorable skeletal outcomes, including fractures and bone loss. A 25(OH)D level of >50 nmol/L or 20 ng/ml is, therefore, the primary treatment goal, although some data suggest a benefit for a higher threshold. Severe vitamin D deficiency with a 25(OH)D concentration below <30 nmol/L (or 12 ng/ml) dramatically increases the risk of excess mortality, infections, and many other diseases, and should be avoided whenever possible. The data on a benefit for mortality and prevention of infections, at least in severely deficient individuals, appear convincing. Vitamin D is clearly not a panacea, and is most likely efficient only in deficiency. Given its rare side effects and its relatively wide safety margin, it may be an important, inexpensive, and safe adjuvant therapy for many diseases, but future large and well-designed studies should evaluate this further. A worldwide public health intervention that includes vitamin D supplementation in certain risk groups, and systematic vitamin D food fortification to avoid severe vitamin D deficiency, would appear to be important. In this narrative review, the current international literature on vitamin D deficiency, its relevance, and therapeutic options is discussed.

[Electrical muscle stimulation in combination with heat for patients with chronic, nonspecific low back pain : A randomized, double-blind, stratified, placebo-controlled clinical trial]. / Elektrische Muskelstimulation in Kombination mit Wärme bei Patienten mit chronischen unspezifischen Rückenschmerzen : Eine randomisierte, stratifizierte, doppelblinde, placebokontrollierte klinische Studie.

BACKGROUND: Chronic non-specific low back pain (LBP) causes more disability than any other medical condition worldwide. Electrical muscle stimulation in combination with heat (EMS/H) for management of LBP has yet not been properly studied. Our hypothesis was that EMS/H provides better pain relief and improves subjective and objective data compared to standard treatment. METHODS: Between 2015 and 2017, we conducted a 6 week randomized, double-blind, stratified, placebo controlled clinical trial, comparing two different forms of EMS/H with placebo treatment with a follow-up 12 weeks after randomization. Patients >18 years with LBP for >6 months and a pain intensity of numerical rating scale (NRS) ≥4/10 were enrolled. RESULTS: A total of 100 patients were recruited. Patients were representative of a LBP population with moderate to severe pain (NRS 5.7/10). After 18 treatments, we found a statistically significant pain reduction, which was also observed at the 12 week follow-up. CONCLUSION: EMS/H is an effective and safe method for managing LBP. A clinically relevant and persisting pain reduction, a stable decrease in self-perceived disability, an improvement in both mood and affective characterization as well as sensory characterization of pain, muscle strength and endurance may have a significant impact on the management of LBP.