Christine B. Sieberg*, Sehar Resad, Navil Sethna, and Stacey A Missmer
Chronic pelvic pain (CPP) can result from endometriosis, which can be or over time can become unresponsive to standardized surgical treatment and hormonal therapy- possibly due to excessive pain and sensitivity known as central sensitization. These patients continue to experience significant pain and disability, such as missed school and activities, decreased feelings of accomplishment, and decreased general well being, often leading to symptoms of depression and anxiety. This brief review discusses the role that central sensitization may assume in the etiology of CPP-particularly in adolescent women, because the neural development can be altered during this critical window of development. Detection of central sensitization can identify young women who may potentially benefit from centrally mediated pharmaco therapies that can be coupled with cognitive behavioral approaches to pain management.
Lutfiye Pirbudak*, Neslihan Bayramoglu Tepe
Anxiety worsens pain experienced by patients and positive emotional state decreases the intensity of pain felt by the patient. In the absence of mother, holding nurse’s hand was efficient. In this case report, we aimed to submit three female patients who had an experience of pain and anxiety preoperatively, perioperatively and postoperatively relieved by hand holding or touching of health care.
Sujoy Banik, and Suparna Bharadwaj*
Respiratory malfunction is associated with a variety of intracranial abnormalities. Neurogenic ventilation- perfusion mismatch due to intrapulmonary shunting is a less described phenomenon. Here we report a case of acute or chronic subdural hematoma complicated by acute preoperative arterial hypoxemia due to neurogenic intrapulmonary shunt (NIS). Hypoxemia subsided with surgical drainage of the subdural blood. One hypothesis for the mechanism of this phenomenon is that a disturbance is created in nervous system control of perfusion-ventilation relationships of the lung. Such a mismatch can be diagnosed using Giola’s diagnostic criteria. Quick and definitive relieving of intracranial pressure is the formula to treat NIS.
Ramiro Mireles, Trisha McNamara, Christopher Heard*, Robert Ramsdell, Timothy Votta, and Jerold Lerman
Remifentanil has been widely described for a number of sedation procedures, but concerns of apnea and the relative costs may limit its use. In this study, we substituted remifentanil boluses for fentanyl boluses in an established intravenous sedation protocol for oral surgery procedures. Remifentanil sedation was evaluated through the Richmond Agitation Sedation Score (RASS). The dosing regimen produced a median RASS score corresponding to deep sedation for the duration of the procedure. Compared with the historical controls, the RASS was not statistically different. Time to discharge from the recovery room and incidence of airway obstruction was significantly greater in the historical group as compared to the remifentanil group. The new remifentanil protocol was found to be effective as evidenced by RASS. The use of remifentanil bolus however proved more labor intensive, but appeared to have an acceptable safety profile compared with established standards for the areas of major concern, including apnea, chest wall rigidity, and hypotension. Finally, cost discrepancies between remifentanil and fentanyl could be mitigated through dividing the remifentanil vial between multiple patients. Overall, we concluded that remifentanil bolus, while not superior in the modality, could prove an acceptable substitute during periods of shortage.
Justin Eckler, Timothy Votta, Tiffany Jadoo, and Christopher Heard*
Introduction: Propofol is frequently used as part of a deep IV sedation regimen for third molar extractions. Our clinic experienced severe drug shortages during 2012-2013 resulting in the use of alternative sedation plans. This review reports the use of IV dexmedetomidine load dose, using multiple small boluses as an alternative to propofol in conjunction with midazolam and fentanyl. The quality of sedation and need for additional propofol was evaluated.
Methods: After Investigational Review Board (IRB) approval we performed a retrospective review of our QA database with respect to this sedation technique. Data collection included patient demographics, drug dosing, cardio-respiratory parameters, sedation assessment and complications. Dexmedetomidine (0.7 mcg/kg) was administered as 4 boluses, along with 2 doses of 2 mg midazolam and 1 dose of 100 mcg fentanyl. After a 6-minute pause to allow adequate time for dexmedetomidine onset the procedure was started and adjunct propofol 10 mg increments were used if needed.
Results: The charts of 70 patients were reviewed, mean age of 17.7 years. In 46% of the patient’s deep sedation was satisfactorily provided without the need for propofol. The mean BIS score of 65 was no different to those patients who required propofol for satisfactory sedation. The discharge times for those patients who did or did not receive propofol was not different. The incidence of airway complications was no lower in the dexmedetomidine only group.