Diabetic Neuropathy: Pathophysiology Review.

PURPOSE OF REVIEW: Diabetic neuropathy is a debilitating complication of diabetes mellitus that affects millions of individuals worldwide. It is characterized by nerve damage resulting from prolonged exposure to high blood glucose levels. Diabetic neuropathy may cause a range of symptoms, including pain, numbness, muscle weakness, autonomic dysfunction, and foot ulcers, potentially causing significant impairment to the quality of life for those affected. This review article aims to provide a comprehensive overview of the pathophysiology of diabetic neuropathy. The etiology of diabetic neuropathy will be discussed, including risk factors, predisposing conditions, and an overview of the complex interplay between hyperglycemia, metabolic dysregulation, and nerve damage. Additionally, we will explore the molecular mechanisms and pathways of diabetic neuropathy, including the impact of hyperglycemia on nerve function, abnormalities in glucose metabolism, the role of advanced glycation end products (AGEs), and inflammatory and immune-mediated processes. We will provide an overview of the various nerve fibers affected by diabetic neuropathy and explore the common symptoms and complications associated with diabetic neuropathy in the pain medicine field. RECENT FINDINGS: This review highlights advances in understanding the pathophysiology of diabetic neuropathy as well as reviews potential novel therapeutic strategies and promising areas for future research. In conclusion, this review article aims to shed light on the pathophysiology of diabetic neuropathy, its far-reaching consequences, and the evolving strategies for prevention and management. In understanding the mechanisms of diabetic neuropathy and the ongoing research in this area, healthcare professionals can better serve patients with diabetes, ultimately improving well-being and reducing complications.

2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting Duration-A Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting.

These practice guidelines are a modular update of the "Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures." The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

Women Representation in Anesthesiology Society Leadership Positions.

BACKGROUND: Although the number of women in medicine has increased, women remain underrepresented in leadership positions, specifically in medical societies. Specialty societies in medicine are influential in networking, career advancement, research and education opportunities, and providing awards and recognition. The goals of this study are to examine the representation of women in leadership positions in anesthesiology societies compared to women society members and women anesthesiologists and to analyze the trend in women society presidents over time. METHODS: A list of anesthesiology societies was obtained from the American Society of Anesthesiology (ASA) website. Society leadership positions were obtained via the societies' websites. Gender was determined by images on the society website and images or pronouns on hospital websites and research databases. The percentage of women presidents, vice presidents/presidents-elect, secretaries/treasurers, board of directors/council members, and committee chairs was calculated. The percentage of women in society leadership positions was compared to the percentage of women society members when available, and the percentage of women anesthesiologists in the workforce (26%) using binomial difference of unpaired proportions tests. The trend of women presidents from 1980 to 2020 was analyzed using a Cochran-Armitage trend test. RESULTS: A total of 13 societies were included in this study. Overall, women held 32.6% (189/580) of leadership positions. 38.5% (5/13) of presidents, 17.6% (3/17) of presidents-elect/vice presidents, and 45% (9/20) of secretaries/treasurers were women. In addition, 30.0% (91/303) of board of directors/council members and 34.2% (90/263) of committee chairs were women. The percentage of women holding society leadership positions was significantly greater than the percentage of women anesthesiologists in the workforce ( P < .001), as was the percentage of women as committee chairs ( P = .003). The percentage of women society members was available for 9 of 13 societies (69%), and the percentage of women leaders was similar to the percentage of women society members ( P = .10). There was a significant difference in the percentage of women leaders between society size categories. Small societies had 32.9% (49/149) women leaders, medium had 39.4% (74/188) women leaders, and the single large society had 27.2% (66/243) ( P = .03). There were also significantly more women leaders in the Society of Cardiovascular Anesthesiologists (SCA) than there are women members ( P = .02). CONCLUSIONS: This study suggests that anesthesia societies may be more inclusive of women in leadership positions compared to other specialty societies. Although in anesthesiology, women remain underrepresented in academic leadership roles, there is a higher proportion of women in leadership roles in anesthesiology societies than proportion of women in the anesthesia workforce.

Addressing Bias in Acute Postoperative Pain Management.

PURPOSE OF REVIEW: This review evaluates disparities in acute postoperative pain management with regard to gender, race, socioeconomic status, age, and language. Strategies for addressing bias are also discussed. RECENT FINDINGS: Inequities in acute postoperative pain management may lead to longer hospital stays and adverse health outcomes. Recent literature suggests that there are disparities in acute pain management related to patient gender, race, and age. Interventions to address these disparities are reviewed but require further investigation. Recent literature highlights inequities in postoperative pain management, particularly in relation to gender, race, and age. There is a need for continued research in this area. Strategies such as implicit bias training and using culturally competent pain measurement scales may help reduce these disparities. Continued efforts by both providers and institutions to address and eliminate biases in postoperative pain management are needed to ensure better health outcomes.

Dexmedetomidine-associated diabetes insipidus during skull base surgery in a pediatric patient.

Diabetes insipidus is characterized by polyuria due to an inability to auto-regulate water balance resulting in dangerous metabolic derangements. Intraoperative anesthetics have been increasingly identified as a cause of diabetes insipidus in adult patients; however, it is rare in pediatrics. We present a case of a 16-year-old male undergoing resection of a recurrent left juvenile nasopharyngeal angiofibroma who experienced intraoperative polyuria concerning diabetes insipidus. Urine output drastically decreased following discontinuation of dexmedetomidine with complete resolution within 24 h. We conclude that this case of transient diabetes insipidus was associated with dexmedetomidine administration.

Representation of Women as Editors in Anesthesiology Journals.

BACKGROUND: Although there has been a considerable increase in the representation of women in medicine, a gender gap still exists with regard to leadership positions. This gender discrepancy has been identified in the field of anesthesiology, in terms of first and senior authorship, as well as in general composition of editorial boards in Anesthesiology and Anesthesia & Analgesia. The goal of this study is to examine the current representation of women in editorial boards of anesthesia journals with respect to the hierarchy of different editorial positions and to assess whether there has been improvement toward equity in recent years. METHODS: A comprehensive search was performed for anesthesiology journals indexed in the Scimago Journal and Country Rank in May 2020. The editorial boards of the top 20 journals by impact factor were analyzed. Editorial board members were categorized based on their title. Gender was assigned using images or pronouns on research databases or hospital-affiliated websites. The percentage of women within each category was calculated. When available, the year the editors obtained their medical degree was collected. A binomial proportion test was used to analyze the distribution of women overall and among editorial roles, compared to the proportion of women anesthesiologists (26%). A Wilcoxon rank-sum test was used to compare time since medical degree between genders. Additionally, women representation in anesthesiology editorial boards in 2020 was compared to 2010. RESULTS: A total of 19 journals were included in this study, as 1 journal did not disclose editorial board membership. Overall, women occupied 18% of all editorial board positions. All editors-in-chief and assistant/associate/deputy editors-in-chief were men. Women consisted of 17.1% of executive/section/senior editors, 17.9% of editors, and 20.6% of associate/assistant editors. There were significantly fewer women editorial board members than the percentage of women anesthesiologists (18% vs 26%; P < .001). Editorial boards from 2010 were available for 14 journals, and of these journals, women comprised 12% of editorial board members in 2010 compared to 19% in 2020 (P = .001). CONCLUSIONS: These findings suggest that in anesthesiology journals, women are underrepresented at all editorial levels, especially at higher levels. As editorial boards have a significant impact on which articles are published by a journal and thereby significant influence on the specialty as a whole, the lack of gender equity in editorial boards should be addressed.

Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature.

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 29 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

Prepectoral Breast Reconstruction Reduces Opioid Consumption and Pain After Mastectomy: A Head-to-Head Comparison With Submuscular Reconstruction.

BACKGROUND: Acute pain after mastectomy is increased with concurrent breast reconstruction. One postulated advantage of prepectoral breast reconstruction is less postoperative pain; however, no comparisons to partial submuscular reconstruction have been made to date. Here, we examined the postoperative pain experienced between patients with prepectoral and subpectoral breast reconstruction after mastectomy. METHODS: We performed a retrospective chart review of all patients undergoing immediate breast reconstruction with tissue expanders from 2012 to 2019 by a single plastic surgeon. Patient demographics, surgical details, and anesthetic techniques were evaluated, and our primary outcome compared postoperative opioid usage between prepectoral and subpectoral reconstructions. Our secondary outcome compared pain scores between techniques. RESULTS: A total of 211 subpectoral and 117 prepectoral reconstruction patients were included for analysis. Patients with subpectoral reconstructions had higher postoperative opioid usage (80.0 vs 45.0 oral morphine equivalents, P < 0.001). Subpectoral patients also recorded higher maximum pain scores compared with prepectoral reconstructions while admitted (7 of 10 vs 5 of 10, P < 0.004). Multivariable linear regression suggests that mastectomy type and subpectoral reconstruction were significant contributors to postoperative opioid use (P < 0.05). CONCLUSIONS: Prepectoral breast reconstruction was associated with less postoperative opioid consumption and lower postoperative pain scores as compared with subpectoral reconstruction, when controlling for other surgical and anesthesia factors. Future randomized controlled trials are warranted to study how postoperative pain and chronic pain are influenced by the location of prosthesis placement in implant-based postmastectomy breast reconstruction.

Intraoperative fluid management and kidney transplantation outcomes: A retrospective cohort study.

BACKGROUND: Patients undergoing kidney transplantation traditionally receive liberal amounts of fluid during surgery. However, excessive fluids can lead to fluid overload and ileus. In this retrospective cohort study, we compared the effect of restrictive versus liberal fluid therapy on kidney transplantation outcomes. METHODS: Patients who underwent deceased-donor kidney transplantation at Mayo Clinic from January 2014 to March 2019 were included. Those who received <3 L of intravenous fluids intraoperatively were categorized as "restrictive;" those who received ≥3 L were categorized as "liberal." The primary outcome was incidence of delayed graft function (DGF). Secondary outcomes included length of stay, readmission within 30 days, time to return of bowel function, and incidence of postoperative complications. RESULTS: Of the 1171 patients included, 557 were in the restrictive group and 614 in the liberal group. The mean (SD) fluid intake was 2.17 (.54) L in the restrictive group and 3.67 (.68) L in the liberal group (P<.001). There was no difference in DGF (relative risk, 1.03; P = .56), length of stay (P = .34), readmission (P = .80), return of bowel function (P = .71), or other postoperative complications. CONCLUSIONS: Intraoperative restrictive fluid therapy during kidney transplantation was not associated with DGF or worse outcomes when compared with liberal fluid therapy.

Patient safety education in anesthesia: current state and future directions.

PURPOSE OF REVIEW: Although patient safety is a core component of education in anesthesiology, approaches to implementation of education programs are less well defined. The goal of this review is to describe the current state of education in anesthesia patient safety and the ideal patient safety curriculum. RECENT FINDINGS: Anesthesiology has been a pioneer in patient safety for decades, with efforts amongst national organizations, such as the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation to disseminate key standards and guidelines in patient safety. However, few, if any strategies for implementation of a patient safety curriculum in anesthesiology exist. SUMMARY: Patient safety education is crucial to the field of anesthesiology, particularly with the advancement of surgical and anesthesia technologies and increasing complexity of patients and procedures. The ideal patient safety curriculum in anesthesiology consists of simulation, adverse event investigation and analysis, and participation in process improvement. Efforts in education must adapt with changing technology, shifts in the way anesthesia care is delivered, and threats to physician wellness. Future efforts in education should harness emerging platforms, such as social media, podcasts, and wikis.

Dexmedetomidine in Enhanced Recovery After Surgery (ERAS) Protocols for Postoperative Pain.

PURPOSE OF REVIEW: Effective acute pain management has evolved considerably in recent years and is a primary area of focus in attempts to defend against the opioid epidemic. Persistent postsurgical pain (PPP) has an incidence of up to 30-50% and has negative outcome of quality of life and negative burden on individuals, family, and society. The 2016 American Society of Anesthesiologists (ASA) guidelines states that enhanced recovery after surgery (ERAS) forms an integral part of Perioperative Surgical Home (PSH) and is now recommended to use a multimodal opioid-sparing approach for management of postoperative pain. As such, dexmedetomidine is now being used as part of ERAS protocols along with regional nerve blocks and other medications, to create a satisfactory postoperative outcome with reduced opioid consumption in the Post anesthesia care unit (PACU). RECENT FINDINGS: Dexmedetomidine, a selective alpha2 agonist, possesses analgesic effects and has a different mechanism of action when compared with opioids. When dexmedetomidine is initiated at the end of a procedure, it has a better hemodynamic stability and pain response than ropivacaine. Dexmedetomidine can be used as an adjuvant in epidurals with local anesthetic sparing effects. Its use during nerve blocks results in reduced postoperative pain. Also, local infiltration of IV dexmedetomidine is associated with earlier discharge from PACU. Perioperative use of dexmedetomidine has significantly improved postoperative outcomes when used as part of ERAS protocols. An in-depth review of the use of dexmedetomidine in ERAS protocols is presented for clinical anesthesiologists.

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. METHODS: In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. RESULTS: The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: -0.2 (95% CI, -1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. CONCLUSIONS: Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and post-operative nausea and vomiting (PONV). However, very few studies describe the application of ERAS to breast surgery and even fewer describe ERAS for outpatient surgery. We describe the implementation and efficacy of an Enhanced Recovery After Surgery (ERAS) pathway for total skin-sparing mastectomy with immediate reconstruction in an outpatient setting. METHODS: We implemented an evidence-based, multimodal ERAS pathway for all patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction at a single 23-h stay surgery center. Highlights of the ERAS pathway included: preoperative acetaminophen, gabapentin, and scopolamine; regional anesthesia for the breast (Pectoral blocks type 1 and 2 or paravertebral block); and intraoperative dexamethasone and ondansetron. This retrospective study included all American Society of Anesthesiology (ASA) Class 1-3 patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction between July 2013 and April 2016. We compared 96 patients who were in the ERAS pathway (ERAS group) to a retrospective cohort of 276 patients (Pre group). The primary outcome was total perioperative opioid consumption. Secondary outcomes were highest postoperative pain scores, incidence of PONV, and length of stay. RESULTS: Patients in the ERAS group had significantly lower total perioperative opioid consumption compared to the Pre group (mean (SD): 111.4 mg (46.0) vs. 163.8 mg (73.2) oral morphine equivalents, p < 0.001). Patients in the ERAS group also had a lower incidence of PONV (28% vs. 50%, p < 0.001). Patients in the ERAS group reported less pain in the recovery room, with a two-point decrease in highest pain score (median [interquartile range (IQR)]: 4 [2,6] in ERAS group vs. 6 [4,7] in Pre group, p < 0.001). There was no clinically significant difference in length of stay (median [IQR]: 1144 min [992, 1259] in ERAS group vs. 1188 [1058, 1344] in Pre group, p = 0.006). CONCLUSION: Implementation of an ERAS pathway for total skin-sparing mastectomy with reconstruction that incorporates regional anesthesia is feasible in a 23-h-stay hospital. Patients in the ERAS pathway had improved post-operative analgesia and reduced post-operative nausea and vomiting.

Deep parasternal intercostal plane nerve block: an anatomical study.

INTRODUCTION: The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ultrasound-guided DPIP block in a human cadaveric model. METHODS: Five ultrasound-guided DPIP blocks were performed in four unembalmed human cadavers using an in-plane approach with a linear transducer oriented in a transverse plane adjacent to the sternum. Twenty milliliters of 0.1% methylene blue were injected between ribs 3 and 4 into the plane deep to the internal intercostal muscles and superficial to the transversus thoracis muscle layer. The chest muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and mediolateral directions. RESULTS: The transversus thoracis muscle slips were stained in all cadavers from 4 to 6 levels. Intercostal nerves were dyed in all specimens. Four levels of intercostal nerves were dyed in each specimen with variability in number of levels stained above and below the level of the injection. CONCLUSIONS: The DPIP block spreads along the tissue plane above the transversus thoracis muscles to multiple levels to dye the intercostal nerves in this cadaver study. This block may be of clinical value for analgesia in anterior thoracic surgical procedures.

Acupuncture as a Complementary Treatment Modality in the Post-Anesthesia Care Setting: A Feasibility Study.

Introduction: Postoperative pain management and postoperative nausea and vomiting are a persistent challenge for both health care providers and patients. Acupuncture is an effective and safe modality for the management of pain and nausea, and has the potential to play a key role in postoperative pain management. This study explores the utility and feasibility of acupuncture in the immediate postoperative setting. Methods: In a retrospective case-control study, 22 patients who underwent elective surgeries and received acupuncture in the post-anesthesia care unit (PACU) were compared with 88 case controls. Indications for acupuncture therapy included persistent pain, nausea, or anxiety. Patient satisfaction and symptom improvement after acupuncture were assessed. PACU nurses and patients were queried on their perspectives on using this therapy. Demographic data, perioperative opioid consumption, pain score in the PACU, incidence of postoperative nausea, PACU length of stay, and unintended hospital admission were assessed. The groups with/without acupuncture were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate. Results: A total of 78.9% of patients receiving acupuncture felt improvement in their symptoms. 94.7% of recovery nurses who cared for patients who received acupuncture felt that it was helpful and 78.9% did not believe it was disruptive. Patients who opted for acupuncture had a statistically significant higher overall median (interquartile range) pain score in the PACU (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0], p = 0. 03). There was no difference between total perioperative opioid consumption between groups (p = 0.94). Conclusions: Most patients who received acupuncture therapy in the PACU were satisfied with their therapy and would recommend it to future patients undergoing surgery. Most recovery nurses felt it was helpful, was not disruptive, and would like to see it utilized in the PACU.