Objective:To revise the “Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult” published in Critical Care Medicine in 2002.Methods:The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task f

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Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Early goal-directed therapy in the treatment of severe sepsis and septic shock

A 72-year-old woman with hypertension presents with a 4-month history of lower back discomfort that radiates to both buttocks and lateral thighs. Previously, she walked 2 miles (3.2 km) a day; now she has difficulty walking two blocks and standing up for more than 15 minutes at a time. Her physical examination is notable only for a slightly stooped posture and a reduction of vibratory sensibility in both great toes. How should she be evaluated and treated?

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Lumbar Spinal Stenosis

Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is moderate. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis.

Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain

Study design Clinical practice guideline Objective To develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain Summary of background data Management of patients with persistent and disabling low back pain remains a clinical challenge A number of interventional diagnostic tests and therapies and surgery are available and their use is increasing, but in some cases their utility remains uncertain or controversial Interdisciplinary rehabilitation has also been proposed as a potentially effective noninvasive intervention for persistent and disabling low back pain Methods A multidisciplinary panel was convened by the American Pain Society Its recommendations were based on a systematic review that focused on evidence from randomized controlled trials Recommendations were graded using methods adapted from the US Preventive Services Task Force and the Grading of Recommendations, Assessment, Development, and Evaluation Working Group Results Investigators reviewed 3348 abstracts A total of 161 randomized trials were deemed relevant to the recommendations in this guideline The panel developed a total of 8 recommendations Conclusion Recommendations on use of interventional diagnostic tests and therapies, surgery, and interdisciplinary rehabilitation are presented Due to important trade-offs between potential benefits, harms, costs, and burdens of alternative therapies, shared decision-making is an important component of a number of the recommendations

Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society.

:Objective:This study was carried out to evaluate the therapeutic effect of epidural steroid injection on pseudoclaudication in patients with lumbar degenerative spinal canal stenosis.Design:Fifty-three patients who complained of pseudoclaudication of less than 20 m in walking distance w

Symptoms of spinal stenosis do not improve after epidural steroid injection

BackgroundThis study was designed to evaluate the effects of sevoflurane with and without nitrous oxide on human middle cerebral artery (MCA) flow velocity, cerebrovascular carbon dioxide reactivity, and autoregulation compared with the awake state using transcranial Doppler ultrasonography.MethodsI

Effects of sevoflurane with and without nitrous oxide on human cerebral circulation. Transcranial Doppler study.

Objective To analyze quantitatively the relationship between sedation and resting energy expenditure or oxygen consumption in postoperative patients. Design A prospective, clinical study. Setting An eight-bed intensive care unit at a university hospital. Patients Thirty-two postoperative patients undergoing either esophagectomy or surgery of malignant tumors of the head and neck who required mechanical ventilation and sedation for > or = 2 days postoperatively. Interventions None. Measurements and main results A total of 133 metabolic measurements were performed. Ramsay sedation scale (RSS), body temperature, and the dose of midazolam were evaluated at the time of the metabolic cart study. All patients received analgesia with buprenorphine at a fixed dose of 0.625 microg x kg(-1) x hr(-1) continuously. Midazolam was used for induction and maintenance of intravenous sedation after admission to the intensive care unit. The initial dose was 0.04 mg x kg(-1) x hr(-1) and was adjusted to achieve a desired depth of sedation at 3, 4, or 5 on the RSS every 4 hrs. The degree of sedation was classified into three states: light sedation (RSS 2-3; n = 49), moderate sedation (RSS 4; n = 39), and heavy sedation (RSS 5-6; n = 45). Results With increasing the depth of sedation, oxygen consumption index (mL x min(-1) x m(-2)), resting energy expenditure index (REEI; kcal x day(-1) x m(-2)), and REE/basal energy expenditure (BEE) decreased significantly. Oxygen consumption index (mean +/- SD), REEI, and REE/BEE were 151 +/- 18, 1032 +/- 120, and 1.29 +/- 0.17 in the light sedation, 139 +/- 22, 947 +/- 143, and 1.20 +/- 0.16 in the moderate sedation, and 125 +/- 16, 865 +/- 105, and 1.13 +/- 0.12 in the heavy sedation, respectively. Conclusion An increase in the depth of sedation progressively decreases in oxygen consumption index and REEI in postoperative patients.

Quantitative analysis of the relationship between sedation and resting energy expenditure in postoperative patients

The aim of the study was to investigate postoperative analgesia and the opioid-sparing effect of the preoperative administration of intravenous flurbiprofen axetil in patients undergoing spinal fusion surgery. Thirty-six patients were randomly allocated into one of three groups. Group A received preoperative flurbiprofen axetil, 1 mg·kg−1. Group B received postoperative flurbiprofen axetil, 1 mg·kg−1. Group C received a placebo. All groups were given a standardized anesthesia and intravenous morphine via a patient-controlled analgesia device for postoperative analgesia. The pain score was evaluated by a visual analog scale (VAS) at 0 (T0), 1 (T1), 2 (T2), 6 (T3), 12 (T4), and 24 (T5) h after surgery, and the morphine requirement was recorded during the study period. VAS in group A was significantly lower than that in group B at T0 and T1. VAS in group A was significantly lower than that in group C throughout the time course after surgery. Postoperative morphine consumption in group A was significantly lower than that in groups B and C at T0 to T3. As compared with postoperative administration, preoperative administration of intravenous flurbiprofen axetil provides better postoperative analgesia and an opioid-sparing effect in patients undergoing spinal fusion surgery under general anesthesia.

Preoperative administration of intravenous flurbiprofen axetil reduces postoperative pain for spinal fusion surgery.

Among some kinds of cervical spine surgeries, combined anterior-posterior cervical spine surgery (CAP-CS surgery) requires prolonged operative time and highly invasive procedure. This study was performed to determine whether CAP-CS surgery was associated with increased risk of emergency airway management compared with other cervical spine surgeries (O-CS surgeries). The records of the patients who underwent cervical spine surgery between July 2001 and March 2003 at our institution were reviewed retrospectively, and we determined whether the CAP-CS surgery was associated with an increased risk of emergency airway management in comparison with O-CS surgeries, using the logistic regression analysis. A total of 165 were eligible for inclusion in the study. A total of 127, 20, 11, 5, and 2 patients suffered from cervical myelopathy, traumatic cervical spinal cord injury, atlantoaxial dislocation, cervical spinal tumors, and cervical pyogenic spondylitis, respectively. The operative approaches were CAP-CS surgery, anterior surgery, posterior surgery, and atlantoaxial surgery in 10, 56, 88, and 11 patients, respectively. Thus, the operative approaches were CAP-CS surgery in 10 patients and O-CS surgeries in 155 patients. Postoperative emergency airway management was required in 7 of the 10 patients (70%) who underwent CAP-CS surgery, and 2 of the 155 patients (1%) who underwent O-CS surgeries. The increased risk of postoperative emergency airway management imposed by CAP-CS surgery was 178.5 by an odds ratio, with a 95% confidence interval of 25.6 to 1246. The results show that CAP-CS surgery provides a major risk factor for postoperative emergency airway management.

Makoto Fukusaki

Papers

Symptoms of spinal stenosis do not improve after epidural steroid injection

Effects of sevoflurane with and without nitrous oxide on human cerebral circulation. Transcranial Doppler study.

Quantitative analysis of the relationship between sedation and resting energy expenditure in postoperative patients

Preoperative administration of intravenous flurbiprofen axetil reduces postoperative pain for spinal fusion surgery.

Increased Incidence of Emergency Airway Management After Combined Anterior-Posterior Cervical Spine Surgery