Suprazygomatic Access for Continuous Bilateral Mandibular Nerve Block for Pain and Trismus Relief in the Tetraplegic Patient.

PURPOSE: Extraoral mandibular nerve block (MNB) is used in oropharyngeal surgery for analgesia and anesthesia. Repeated or continuous MNB has been used successfully as treatment for uncontrollable pain, masseter spasticity, and airway assessment. The usual technique involves transcutaneous infrazygomatic access. However, in some specific settings, this approach is not always feasible. MATERIALS AND METHODS: A continuous bilateral MNB with a suprazygomatic approach to the pterygomandibular space was used to resolve a case of refractory and painful trismus in a patient with tetraplegia. RESULTS: Analgesia was achieved and maintained by bilateral catheter placement to the pterygomandibular space and repeated injection of local anesthetic for 48 hours. The right-side catheter was accidentally withdrawn; the left-side catheter was maintained up to 72 hours. The efficiency of analgesia was not affected. This block provided effective analgesia within the first few hours after local anesthetic injection, helped to improve mouth opening, and resolved acute pain. Because kinesitherapy could be introduced, the patient was left on nonopioid analgesics. CONCLUSION: Continuous bilateral MNB through the suprazygomatic approach was used safely and efficiently. The suggested approach is quite unique, as is the clinical circumstance, and might be considered when the usual technique is challenging.

Population pharmacokinetic model of free and total ropivacaine after transversus abdominis plane nerve block in patients undergoing liver resection.

AIMS: The aim of this study was to develop a pharmacokinetic model in order to characterize the free and total ropivacaine concentrations after transversus abdominis plane block in a population of patients undergoing liver resection surgery. In particular, we evaluated the impact of the size of liver resection on ropivacaine pharmacokinetics. METHODS: This work is based on a single-centre, double-blinded, randomized, placebo-controlled study. Among the 39 patients included, 19 patients were randomized to the ropivacaine group. The free and total ropivacaine concentrations were measured in nine or 10 blood samples per patient. A pharmacokinetic model was built using a nonlinear mixed-effect modelling approach. RESULTS: The free ropivacaine concentrations remained under the previously published toxic threshold. A one-compartment model, including protein binding site with a first-order absorption, best described the data. The protein binding site concentration was considered as a latent variable. Bodyweight, the number of resected liver segments and postoperative fibrinogen evolution were, respectively, included in the calculation of the volume of distribution, clearance and binding site production rate. The resection of three or more liver segments was associated with a 53% decrease in the free ropivacaine clearance. CONCLUSIONS: Although large liver resections were associated with lower free ropivacaine clearance, the ropivacaine pharmacokinetic profile remained within the safe range after this type of surgery.

Health Care Resource Use and Total Mortality After Hospital Admission for Severe COVID-19 Infections During the Initial Pandemic Wave in France: Descriptive Study.

BACKGROUND: Little is known about post-hospital health care resource use (HRU) of patients admitted for severe COVID-19, specifically for the care of patients with postacute COVID-19 syndrome (PACS). OBJECTIVE: A list of HRU domains and items potentially related to PACS was defined, and potential PACS-related HRU (PPRH) was compared between the pre- and post-COVID-19 periods, to identify new outpatient care likely related to PACS. METHODS: A retrospective cohort study was conducted with the French National Health System claims data (SNDS). All patients hospitalized for COVID-19 between February 1, 2020, and June 30, 2020 were described and investigated for 6 months, using discharge date as index date. Patients who died during index stay or within 30 days after discharge were excluded. PPRH was assessed over the 5 months from day 31 after index date to end of follow-up, that is, for the post-COVID-19 period. For each patient, a pre-COVID-19 period was defined that covered the same calendar time in 2019, and pre-COVID-19 PPRH was assessed. Post- or pre- ratios (PP ratios) of the percentage of users were computed with their 95% CIs, and PP ratios>1.2 were considered as "major HRU change." RESULTS: The final study population included 68,822 patients (median age 64.8 years, 47% women, median follow-up duration 179.3 days). Altogether, 23% of the patients admitted due to severe COVID-19 died during the hospital stay or within the 6 months following discharge. A total of 8 HRU domains were selected to study PPRH: medical visits, technical procedures, dispensed medications, biological analyses, oxygen therapy, rehabilitation, rehospitalizations, and nurse visits. PPRs showed novel outpatient care in all domains and in most items, without specificity, with the highest ratios observed for the care of thoracic conditions. CONCLUSIONS: Patients hospitalized for severe COVID-19 during the initial pandemic wave had high morbi-mortality. The analysis of HRU domains and items most likely to be related to PACS showed that new care was commonly initiated after discharge but with no specificity, potentially suggesting that any impact of PACS was part of the overall high HRU of this population after hospital discharge. These purely descriptive results need to be completed with methods for controlling for confusion bias through subgroup analyses. TRIAL REGISTRATION: ClinicalTrials.gov NCT05073328; https://clinicaltrials.gov/ct2/show/NCT05073328.

Systematic Review of the Use of Phytochemicals for Management of Pain in Cancer Therapy.

Pain in cancer therapy is a common condition and there is a need for new options in therapeutic management. While phytochemicals have been proposed as one pain management solution, knowledge of their utility is limited. The objective of this study was to perform a systematic review of the biomedical literature for the use of phytochemicals for management of cancer therapy pain in human subjects. Of an initial database search of 1,603 abstracts, 32 full-text articles were eligible for further assessment. Only 7 of these articles met all inclusion criteria for this systematic review. The average relative risk of phytochemical versus control was 1.03 [95% CI 0.59 to 2.06]. In other words (although not statistically significant), patients treated with phytochemicals were slightly more likely than patients treated with control to obtain successful management of pain in cancer therapy. We identified a lack of quality research literature on this subject and thus were unable to demonstrate a clear therapeutic benefit for either general or specific use of phytochemicals in the management of cancer pain. This lack of data is especially apparent for psychotropic phytochemicals, such as the Cannabis plant (marijuana). Additional implications of our findings are also explored.