RESUMEN
The pain conditions and comorbidities experienced by injured service members and the challenge of pain management by the military medical system offer a unique opportunity to inform pain management and medical research. In this article, acute and chronic pain issues, current treatment options and limitations, as well as novel approaches to pain management are discussed within the context of combat casualty care, from the battlefield to hospitalization and rehabilitation. This review will also highlight the current pain management limitations that need to be addressed in future clinical and basic science research to improve care for our nation's injured service members.
Asunto(s)
Medicina Militar/métodos , Manejo del Dolor , Heridas y Lesiones/terapia , Campaña Afgana 2001- , Dolor Crónico/etiología , Servicios Médicos de Urgencia/métodos , Humanos , Guerra de Irak 2003-2011 , Manejo del Dolor/métodos , Manejo del Dolor/tendencias , Factores de Riesgo , Trastornos Relacionados con Sustancias/etiología , Heridas y Lesiones/rehabilitaciónRESUMEN
BACKGROUND: When urgently intubating patient in the burn intensive care unit (BICU), various induction agents, including propofol, are utilized that may induce hemodynamic instability. METHODS: A retrospective review was performed of consecutive critically ill burn patients who underwent urgent endotracheal intubation in BICU. Basic burn-related demographic data, indication for intubation, and induction agents utilized were recorded. The primary outcomes of interest were clinically significant hypotension requiring immediate fluid resuscitation, initiation or escalation of vasopressors immediately after intubation. Secondary outcomes included ventilator days, stay length, and in-hospital mortality. RESULTS: Between January 2003 and August 2010, we identified 279 urgent intubations in 204 patients. Of these, the criteria for presumed sepsis were met in 60% (n=168) of the intubations. After intubation, 117 patients (42%) experienced clinically significant hypotension. Propofol (51%) was the most commonly utilized induction agent followed by etomidate (23%), ketamine (15%), and midazolam (11%). On multiple logistic regression, %TBSA (OR 1.016, 95% CI 1.004-1.027, p<0.001) and presumed sepsis (OR 1.852, 95% CI 1.100-3.117, p=0.02) were the only significant predictors of hypotension. None of the induction agents, including propofol, were significantly associated with hypotension in patients with or without presumed sepsis. CONCLUSIONS: In critically ill burn patients undergoing urgent endotracheal intubation, specific induction agents, including propofol, were not associated with clinically significant hypotension. Presumed sepsis and %TBSA were the most important risk factors.
Asunto(s)
Quemaduras/terapia , Hipotensión/etiología , Intubación Intratraqueal/efectos adversos , Adulto , Unidades de Quemados , Quemaduras/complicaciones , Quemaduras/mortalidad , Cuidados Críticos/métodos , Femenino , Fluidoterapia/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Hipnóticos y Sedantes/efectos adversos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Sepsis/complicaciones , Factores de Tiempo , Vasoconstrictores/administración & dosificaciónRESUMEN
Effective cancer pain management requires multidisciplinary approaches for multimodal analgesia. Although opioids have been the cornerstone, developments such as regional anesthesia and interventional pain techniques, complementary and alternative medicine, and new pharmaceuticals also have shown promise to relieve cancer pain. This overview of relevant clinical efforts and the modern day state of the science will afford a better understanding of pain mechanisms and multimodal approaches beneficial in optimizing analgesia for cancer patients.
Asunto(s)
Anestesia/métodos , Neoplasias/complicaciones , Neoplasias/cirugía , Manejo del Dolor/métodos , Dolor/tratamiento farmacológico , Dolor/genética , Investigación Biomédica Traslacional/tendencias , Analgésicos/farmacología , Analgésicos/uso terapéutico , Anestesia/tendencias , Enfermedad Crónica , Codón sin Sentido/efectos de los fármacos , Citocromo P-450 CYP2D6/genética , Drogas en Investigación/farmacología , Drogas en Investigación/uso terapéutico , Genotipo , Humanos , Canal de Sodio Activado por Voltaje NAV1.7 , Dolor/etiología , Manejo del Dolor/tendencias , Polimorfismo de Nucleótido Simple/efectos de los fármacos , Calidad de Vida , Canales de Sodio/genéticaRESUMEN
BACKGROUND: Acute pain after injury affects the comfort and function of the wounded soldier and the physiology of multiple body systems. In the civilian population, pain alters the function of the autonomic nervous system, causing increased heart rate and blood pressure. However, there are no data regarding the impact of combat-related pain on physiologic responses. This study is a retrospective analysis that examined the relationship of pain and physiologic parameters in injured soldiers. METHODS: After Institutional Review Board approval, the Joint Trauma Theater Registry (JTTR) was queried to identify soldiers who had pain scores recorded in the Emergency Department (ED) in theater. Subject data collected from the JTTR included the following: pain score, Injury Severity Score (ISS), blood pressure, heart rate, and respiratory rate. RESULTS: We identified 2,646 soldiers with pain scores recorded in the ED. The pain score was not related to most physiologic parameters measured in the ED. Pain intensity had no correlation with blood pressure or heart rate. However, there were relationships between the pain score and respiratory rate, with patients reporting a pain score of 10 having a slightly higher respiratory rate. Increasing pain scores were also associated with increased ISS (p < 0.001). CONCLUSIONS: In contrast to data from civilian patients, early pain scores were not related to heart rate or blood pressure. A pain score of 10 corresponded to an increased respiratory rate. Despite little relationship between pain and injury severity in the civilian population, the increasing ISS was proportional to the pain scale in wounded soldiers.