RESUMEN
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
Asunto(s)
Hombro , Humanos , Hombro/cirugía , Anestesia/métodos , Bloqueo Nervioso/métodos , Posicionamiento del Paciente/métodosRESUMEN
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
Asunto(s)
Bloqueo Nervioso , Hombro , Humanos , Bloqueo Nervioso/métodos , Posicionamiento del Paciente , Hombro/cirugíaRESUMEN
BACKGROUND: Ketamine, a potent analgesic and N-methyl-D-aspartate-(NMDA)-receptor antagonist, improves analgesic outcomes in patients with complex regional pain syndrome (CRPS). The NMDA receptor has also been implicated in opioid withdrawal. The use of ketamine to assist with a rapid opioid taper in the setting of CRPS has not been previously described. CASE: We present a case in which a 5-day continuous ketamine infusion was utilized in a robust multimodal analgesia regimen in combination with cognitive behavioral therapy (CBT) to successfully taper a patient with complex regional pain syndrome (CRPS) who was taking 330 mg of daily morphine equivalents completely off of opioids, minimize withdrawal symptoms, and produce sustained results. DISCUSSION: CRPS may involve catecholamine hypersensitivity and central sensitization and can be notoriously challenging to treat by itself even outside of the context of an opioid taper. The patient we describe here received one additional 5-day infusion at 6 months and remained opioid-free while experiencing a major improvement in function and lifestyle that he still maintains. This was possible through a combination of aggressive inpatient management with ketamine as the centerpiece, followed by consistent outpatient CBT to maintain results without the need for a return to opioids. This combination has previously not been described in the setting of a rapid opioid taper and this patient's underlying CRPS made it all the more remarkable.
Asunto(s)
Analgésicos/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Ketamina/uso terapéutico , Trastornos Relacionados con Opioides/terapia , Síndrome de Abstinencia a Sustancias/terapia , Analgésicos Opioides/efectos adversos , Estudios de Seguimiento , Humanos , Hidromorfona/efectos adversos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Manejo del Dolor/métodos , Distrofia Simpática Refleja/tratamiento farmacológicoRESUMEN
BACKGROUND: Vitamin D deficiency is common in the United States. Regardless of whether or not vitamin D deficiency increases the risk of cancer and decreases survival of cancer, the established adverse impact of its deficiency on bone health is of particular concern for cancer patients. The extent of vitamin D deficiency is not well defined in the oncology setting, and there are no standardized protocols for screening and supplementation for individuals found to be deficient in vitamin D. OBJECTIVE: To determine the prevalence of vitamin D deficiency as measured by levels of serum 25-hydroxyvitamin D (25[OH]D) in cancer patients at an outpatient oncology practice. METHODS: A total of 177 patients representing a range of oncologic diagnoses were tested for 25(OH)D between January 1, 2011 and December 31, 2011. Suboptimal vitamin D levels were defined either as less than 20 ng/mL or less than 30 ng/mL, according to standards proposed by the Institute of Medicine and the Endocrine Society, respectively. LIMITATIONS: The point of testing was subjective to the clinician. Some patients may have had their vitamin D levels tested and treated elsewhere, therefore that data was not captured. RESULTS: At baseline, 18.1% of patients tested had vitamin D levels of less than 20 ng/ml, and 49.1% of patients had vitamin D levels of less than 30 ng/ml. Follow-up rates were low. In all, 54% of patients with 25(OH)D levels of less than 30 ng/ml obtained a second reading, and only 38% of those patients achieved sufficient levels at the second reading. CONCLUSION: Vitamin D deficiency is prevalent in patients with cancer and should be monitored in patients who are at high risk for vitamin D deficiency or poor bone health.