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The management of pain after burn injuries is a clinical challenge magnified in patients with significant comorbidities. Presently, burn pain is treated via a wide variety of modalities, including systemic pharmacotherapy and regional analgesia. Although the latter can provide effective pain control in patients with burn injuries, it is relatively underused. Furthermore, the development of ultrasound guidance has allowed for novel approaches and sparing of motor nerve blockade with preference toward sensory-specific analgesia that has not been possible previously. This can result in decreased opiate use and shorter latency to initiation of rehabilitation. In this report, we describe a patient with chronic pain, morbid obesity, and severe sleep apnea who presented with uncontrolled pain resulting from a burn injury to the dorsum of his feet. The treatment consisted of multimodal analgesia and placement of bilateral continuous superficial peroneal nerve catheters, as he underwent skin grafting and postprocedural hydrotherapy. This novel approach allowed for sparing of postprocedural opiates with positive clinical results.
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PMID:The benefits of ultrasound-guided continuous sensory nerve blockade in the setting of burn injury: a case report of bilateral continuous superficial peroneal nerve blockade in a patient with severe sleep apnea. 2818 76

Tonsillectomy is one of the most common paediatric surgical procedures performed in Australasia. The aim of this paper is to provide an up-to-date review of the indications for the procedure (and the evidence base for each of these indications), as well as describe the surgical technique and perioperative management and risks for a non-surgical audience. The primary indications for tonsillectomy are obstructive sleep apnoea (OSA) (where it is most commonly performed in association with adenoidectomy) and recurrent pharyngotonsillitis. There is now high-quality evidence that tonsillectomy improves objective measures of OSA on sleep studies, as well as quality of life and child behaviour. The impact of surgery on cognitive function is less well delineated. For recurrent pharyngotonsillitis, tonsillectomy has a modest impact on recurrent sore throat symptoms - clinicians should ensure an appropriate pre-operative observation period and adequately discuss the potential benefits with parents prior to surgery. Traditional approaches to tonsillectomy involve surgically dissecting the entire tonsil from the underlying pharyngeal muscle. Subtotal tonsillectomy (intracapsular tonsillectomy or tonsillotomy) is described for OSA and may reduce perioperative morbidity. Children younger than 3 years and those with moderate to severe OSA or significant comorbidities should be admitted for overnight observation. Simple analgesia is adequate for most patients postoperatively. Codeine is contraindicated due to reports of postoperative death due to respiratory suppression. Overall, tonsillectomy is a well-tolerated procedure, with pain and postoperative haemorrhage (2-4%) being the most common complications. Haemorrhage can be life threatening; however, the mortality rate remains very small at approximately 1:30 000.
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PMID:Current perspectives on the role of tonsillectomy. 2914 1

Postoperative pulmonary complications are a major determinant of outcome for patients and consume huge resources within hospital, particularly in critical care. Prediction and anticipation of postoperative pulmonary complications are vital for patient selection and, in some cases, for informed patient consent. Being able to assess the likelihood of postoperative pulmonary complications also allows research into methods to reduce them by allowing allocation of patients to the appropriate arms of research trials. Some patients have pre-operative characteristics or belong to patient groups such as those with chronic obstructive pulmonary disease or obstructive sleep apnoea, where techniques and evidence-based guidance to avoid or reduce complications are becoming established. Intra-operative ventilation and the use of lung-protective ventilation may be helpful during major surgery, but studies looking at reduced tidal volumes, recruitment and levels of positive end-expiratory pressure, have this far only led to a degree of consensus in terms of tidal volume, although parameters that predispose to postoperative pulmonary complications are becoming clearer. Optimal postoperative care in terms of analgesia, positioning, physiotherapy and mobilisation is another developing area. Techniques such as continuous positive airways pressure, non-invasive ventilation and high-flow nasal humidified oxygen appear to show some benefit, but the exact roles, pressures and timings of each are currently being explored. Much remains to be researched and developed into evidence-based practice.
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PMID:Respiratory complications of anaesthesia. 2931 6

Opioid-free anaesthesia (OFA) is a technique where no intraoperative systemic, neuraxial or intracavitary opioid is administered with the anaesthetic. Opioid-free analgesia similarly avoids opioids in the perioperative period. There are many compelling reasons to avoid opioids in the surgical population. A number of case reports and, increasingly, prospective studies from all over the world support its benefits, especially in the morbidly obese population with or without sleep apnoea. A derivative technique is opioid sparing, where the same techniques are used but some opioid use is allowed. This chapter is a review of the current knowledge regarding opioid-free or low-dose opioid anaesthetic and analgesic techniques for the following special populations: obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, acute/chronic opioid addiction and cancer surgery. Practical aspects include sympatholysis, analgesia and Minimum Alveolar Concentration (MAC) reduction with dexmedetomidine; analgesia with low-dose ketamine and co-anaesthesia; and sympatholysis with intravenous lignocaine. Non-opioid adjuvants such as NSAIDS, paracetamol, magnesium, local anaesthetic infiltration and high-dose steroids are added in the perioperative period to further achieve co-analgesia. Loco-regional anaesthesia and analgesia are also maximised. It remains to be seen whether OFA and early postoperative analgesia, which similarly avoids opioids, can prevent the development of hyperalgesia and persistent postoperative pain syndromes.
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PMID:Special indications for Opioid Free Anaesthesia and Analgesia, patient and procedure related: Including obesity, sleep apnoea, chronic obstructive pulmonary disease, complex regional pain syndromes, opioid addiction and cancer surgery. 2973 43

Sleep-disordered breathing has a prevalence of 12% in the pediatric population. It represents a spectrum of disorders encompassing abnormalities of the upper airway that lead to sleep disruption, including primary snoring, obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Sleep-disordered breathing is the most common indication for adenotonsillectomy, one of the most common procedures performed in children. In recent years, the American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, and the American Society of Anesthesiologists have crafted guidelines to help safely manage children with sleep-disordered breathing. Each organization recommends in-laboratory polysomnography for definitive diagnosis of obstructive sleep apnea in certain cases. However, because this test is both costly and inconvenient, there has been significant interest in alternative methods for diagnosing clinically significant sleep-disordered breathing. Accurate diagnosis is critical because sleep-disordered breathing confers certain perioperative risks and increased mortality in some instances. Recent studies have elucidated the danger of anesthesia and opioids in worsening obstructive sleep apnea, and recommendations for alternative analgesia are being created. In addition, determining the most appropriate level and duration of monitoring in the postoperative period is actively being evaluated. This article presents an overview of the recent literature on the perioperative care of pediatric patients with sleep-disordered breathing. It highlights innovative modalities and limitations in diagnosing obstructive sleep apnea, the importance of a tailored anesthetic/analgesic approach to children with obstructive sleep apnea, and the need for postoperative monitoring. It also brings to focus that further studies on the perioperative care of these children are necessary.
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PMID:Diagnosis and perioperative management in pediatric sleep-disordered breathing. 3061 48

We present the case of a 59-year-old woman with third-grade obesity and severe comorbidities including osteoporosis, dyslipidemia, diabetes mellitus, hypertension, night eating following bariatric biliary-intestinal bypass surgery, severe fibromyalgia, poly-arthrosis, lumbar disc herniation in L5S1, sleep disorders and sleep apnea syndrome, and emotional disorders with anxiety and depression, who suffered from chronic pain unresponsive to a combination of multiple analgesics. After a period of metabolic and nutritional rehabilitation, analgesic treatment with tapentadol prolonged release (PR) was started and gradually increased to a daily dose of 300 mg with optimal pain control and a marked improvement in the quality of life and autonomy. Therapy suspension was followed by rebound pain with a worsening in functional capacity, and thus, the patient requested a new rehabilitation treatment, with new benefits. Analgesia is of paramount importance in fragile patients who are undergoing a rehabilitation period, in order to improve compliance with the rehabilitation protocols and increase the success of behavioral therapy. Tapentadol PR can be an effective analgesic therapy for pain control in several settings. Its peculiar tolerability profile improves the acceptability of tapentadol, even in patients with multiple previous analgesic treatments.
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PMID:Tapentadol prolonged release for pain control in a frail obese patient: a case report. 3175 83


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