Acute Pain Management in Intensive Care Patients: Facts and Figures

Pain is an unpleasant experience for all patients including intensive care patients; if it is not treated properly, it has deleterious effects on patients’ acute and chronic well-beings. In ICU patients, it causes sympathetic stimulation leading to adverse hemodynamic effects and after discharge, these patients are at the higher risk for developing chronic pain and post-traumatic stress disorders. Apart from racial and regional factors, sleep deprivation, anxiety, and delirium increase the pain perceptions. Pain assessment is a prerequisite for adequate pain management. The ICU patients are sedated and ventilated, and assessment scales differ depending on whether the patient is able to communicate. There are different pain assessment scales for both groups of patients. The preferred mode of delivery of analgesic medication is intravenous route as intramuscular and subcutaneous route are not reliable for drug delivery in these patients. Patient and nurse controlled analgesia gives better sense of pain control. In the treatment of pain, opioids are the commonly used medications, but paracetamol, dexmedetomidine, and gabapentin are increasingly used. Newer trends are multimodal analgesia, where the combinations of analgesic medications with different mechanism of action are used. Another trend is increasing use of analgosedation; they not only control the pain but also relieve anxiety

Acute Management of Heat Stroke: Facts and Figures

Heat-related illnesses range from heat exhaustion to heat stroke. Heat stroke is a life-threatening medical emergency causing multiple organ dysfunction that if not treated, can be fatal. It is a severe heat illness with a body temperature of more than 400c and organ dysfunction. Epidemiology of heat stroke varies depending on geographic location, and reported incidences range from 1.98 to 2.89/100000 per year. Heat stroke is classified as exertional or non-exertional. Pathophysiology is exposure to higher temperatures with impaired thermoregulation. Patients will present with high core body temperature; tachypnea, tachycardia, and hypotension may be present. The manifestations of organ dysfunction range from coagulopathy to altered levels of consciousness, and pulmonary edema. Accurate core body temperature measurement with clinical manifestations will diagnose the heat stroke. Early diagnosis, earlier temperature management, and organ supportive care are essential

Cerebral Arteriovenous Malformation from Classification to the Management

Cerebral arteriovenous malformations (cAVMs) are the rare neurosurgical emergency. cAVM is an abnormal vascular web, composed of nidus, feeding artery and draining veins. It commonly occurs in the supratentorial area of the brain. The common grading system used in cAVM is Spetzler-Martin grading, which takes into consideration the size of nidus, the location of cAVM and the venous drainage. The cAVMs may develop flow and pressure-related aneurysms, which will increase the morbidity and mortality in these patients. cAVMs vary in size and undergo growth, remodeling and rarely regression. Most of the cAVMs are asymptomatic, but the common presentation are headache, seizure, intracerebral hemorrhage or focal neurological deficit. The cerebral angiography remains the gold standard for the diagnosis of cAVM. Management of the cAVM includes medical therapy, surgical excision, radiosurgery and embolization

Aneurysmal Subarachnoid Haemorrhage (aSAH) and Hydrocephalus: Fact and Figures

Hydrocephalus (HCP) occurs due to the injurious effect of subarachnoid haemorrhage (SAH). It causes increased morbidity and mortality. It can be acute and frequently occurs within 48 hours and up to 7 days. Subacute hydrocephalus may occur up to 14 days and is chronic if remained or develops after 2 weeks of the subarachnoid haemorrhage. Acute hydrocephalus after aneurysmal subarachnoid (aSAH) bleeding is non-communicating or obstructive and occurs due to physical obstruction by a clot, the effect of blood in the subarachnoid space, and inflammation. Chronic hydrocephalus is due to fibrosis and adhesion, which hampers cerebrospinal fluid (CSF) absorption and increased secretion of CSF from gliosis. Various risk factors for developing hydrocephalus in aneurysmal subarachnoid haemorrhage patients range from female gender to high severity scores. Acute hydrocephalus frequently requires diversion drainage of CSF by external ventricular drain (EVD); it usually subsides within a week, and EVD is removed. Fewer patients will develop or continue to have hydrocephalus, requiring either short or longer shunting of the CSF namely by ventriculoperitoneal shunt or other modes of CSF drainage

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic