Purpose Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complicati... more Purpose Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complications, such as esophageal and vascular injury. The objective of this study was to evaluate the potential for vascular and esophageal injury in healthy subjects by examining the sonoanatomy of the neck relevant to the SGB at the sixth (C6) and seventh (C7) cervical vertebral levels and determining the incidence of blood vessels and esophagi in the simulated path of needle insertion in the conventional and two different ultrasound-guided approaches used to perform a SGB. Methods Ultrasound scanning of the neck at the C6 and C7 cervical vertebral levels was performed in 100 adult subjects, and the following measurements were obtained: the degree of deviation of the esophagus relative to the larynx/trachea; the likelihood of encountering a vessel in This study was conducted with written informed consent from the study subjects. This report describes an observational clinical study, and it adheres to the STROBE guidelines.
Background: Intrathecal morphine is commonly and effectively used for analgesia after joint arthr... more Background: Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty. Methods: This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with lowdose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications. Results: In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m 2 . Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308). Conclusions: Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.
Canadian Medical Association Journal, Sep 30, 2018
Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bh... more Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bhatia and Vincent Chan gathered studies and guidelines, applied them and mapped the order and structure of the papers. All of the authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.
N EUROPATHIC pain is a highly prevalent and often refractory chronic pain condition that is assoc... more N EUROPATHIC pain is a highly prevalent and often refractory chronic pain condition that is associated with substantial disability and deterioration in quality of life. 1 Accumulating evidence suggests that intravenous infusion of ketamine can result in significant relief of refractory neuropathic pain, when the dose is individually titrated to minimize adverse effects and maximize long-term analgesia. 2-5 However, approximately 50% of patients will not respond to this therapy. The factors that contribute to the analgesic effectiveness in some, but not in other patients, are unknown. Here we investigated whether there are noninvasive quantitative sensory testing or measures of brain function that point to aberrant pain mechanisms underlying refractory neuropathic pain that may have prognostic value regarding ketamine treatment. • Ketamine is an N-methyl-D-aspartate antagonist with growing use in the management of chronic pain • Descending pain modulatory circuits are key modulators of chronic pain What This Article Tells Us That Is New • The infusion of ketamine resulted in meaningful pain relief in about 50% of patients with chronic neuropathic pain • The magnitude of temporal summation of pain and the dynamic engagement of the descending pain modulatory circuit predicted treatment efficacy and point to mechanisms by which ketamine can relieve pain
Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has r... more Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has recently been applied to improve locomotion. Several technical challenges are faced by surgeons during SCS lead implantation, particularly in the confined dorsal epidural spaces in patients with spinal degenerative disease, scarring and while targeting challenging structures such as the dorsal root ganglion. Magnetic navigation systems (MNS) represent a novel technology that uses externally placed magnets to precisely steer tethered and untethered devices. This innovation offers several benefits for SCS electrode placement, including enhanced navigation control during tip placement, and the ability to position and reposition the lead in an outpatient setting. Here, we describe the challenges of SCS implant surgery and how MNS can be used to overcome these hurdles. In addition to tethered electrode steering, we discuss the navigation of untethered micro-and nanorobots for wireless and remote neuromodulation. The use of these small-scale devices can potentially change the current standard of practice by omitting the need for electrode and pulse generator implantation or replacement. Open questions include whether small-scale robots can generate an electrical field sufficient to activate neuronal tissue, as well as testing precise navigation, placement, anchoring, and biodegradation of micro-and nanorobots in the in vivo environment.
Background Chronic daily headaches (CDH) are common and associated with significant morbidity, po... more Background Chronic daily headaches (CDH) are common and associated with significant morbidity, poor quality of life, and substantial burden on the healthcare system. CDH tends to be refractory to conventional medical management and/or patients cannot afford expensive treatments. It is stipulated that CDH share a mechanism of central sensitization in the trigeminocervical complex, mediated by activation of the N-methyl-d-aspartate (NMDA) receptors. Ketamine, a non-competitive NMDA antagonist, has been used in the treatment of chronic pain, but its role in CDH has not been completely established. This trial aims to evaluate the effect of high-dose IV ketamine infusions (compared to placebo) on the number of headache days at 28 days post-infusion. Methods A multicenter, placebo-controlled, randomized controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessors. The study will include 56 adults with a CDH diagnosis as per ICHD-3 criteria. Participants will be randomized (1:1) to either ketamine (1 mg. kg -1 bolus followed by infusion of 1 mg. kg -1 . h -1 for 6 h) or placebo (0.9% saline in the same volume and infusion rate as the trial medication) bolus and infusion for 6 h. The impact on the number of monthly headache days, headache intensity, physical activity, mood, sleep, quality of life, analgesic consumption, and adverse effects will be recorded at baseline, immediately post-infusion, and from 1 to 28 days, 29 to 56 days, and 57 to 84 days after the infusion Discussion Despite advancements in treatment, many patients continue to suffer from CDH. This trial investigates whether high-dose IV ketamine infusions can effectively and safely improve the CDH burden as compared to a placebo infusion. This treatment could become a safe, affordable, and widely available option for patients living with refractory headache. Trial registration ClinicalTrials.gov NCT05306899. Registered on
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Apr 1, 2008
Reduced metabolism of morphine can directly and, in combination with encephalopathy (which may re... more Reduced metabolism of morphine can directly and, in combination with encephalopathy (which may result from low residual liver volume), lead to serious, central obtundation. Reduced handling of paracetamol can also lead to exacerbation of potentially compromised liver function. In addition, the surgical stimulus of a large upper abdominal incision with retraction, the resection of sometimes greater than 50% organ volume, and the aim of on-table tracheal extubation, present unique challenges in the provision of adequate analgesia for this type of surgery. Using an intrathecal morphine dose exceeding the dose range of 200-500 µg previously published 2 in combination with a relatively low infusion rate of remifentanil, we observed MAC and opioid-sparing effects, with evidence of adequate analgesia in this particular patient. We did not encounter problems with excessive sedation, respiratory depression, 3 or hyperalgesia. We fully recognize that such a high dose of intrathecal morphine mandates prolonged postoperative monitoring in an appropriate setting. We believe that that this analgesic combination raises a number of interesting clinical points for further investigation and we are currently undertaking a randomized, controlled trial at our centre, to evaluate the efficacy of this technique for patients undergoing major hepatic resection surgery (NCT00553553).
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Dec 4, 2019
Purpose The use of interventional pain management (IPM) modalities to alleviate chronic pain is i... more Purpose The use of interventional pain management (IPM) modalities to alleviate chronic pain is increasing despite the lack of high-quality evidence. We undertook this survey to explore patterns, training, and attributes of IPM practice. Methods We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. Results Of 777 physicians contacted, 256 (33%) responded: 45 (6%) declined to participate and 211 (27%) agreed to participate; the number of participants answering any given question varied. One hundred and sixty-nine of 194 (87%) practiced IPM and 103 of 194 (53%) managed only non-cancer pain. Pain management training of C six months was associated with higher odds of IPM training (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.32 to 6.7), but not necessarily ongoing IPM practice (OR, 1.97; 95% CI, 0.74 to 5.3). A substantial percentage of physicians (108 of 168 [64%]) practiced IPM based only on training received during either their base residency program or courses. Only 48 of 186 (26%) felt that there were adequate opportunities for IPM training, and 69 of 186 (37%) believed that their colleagues practiced IPM in accordance with the best current evidence. Conclusions Our survey indicates that IPM practice and training were not uniform, and that interventional therapies for chronic pain may not be performed in accordance with the best available evidence. Our survey highlights a lack of IPM training opportunities, which may result in substandard training. Concerted efforts involving physician organizations and regulators are needed to standardize IPM training and develop clinical guidelines to optimize evidence-based practice.
International Journal of Environmental Research and Public Health
Patients with implanted medical devices are increasingly referred for hyperbaric oxygen therapy (... more Patients with implanted medical devices are increasingly referred for hyperbaric oxygen therapy (HBOT), and the safety of exposing some of these devices to hyperbaric environments has not previously been explored. There is a paucity of evidence surrounding the management of implanted neurological devices such as neurostimulators and intrathecal drug delivery (IDD) pumps in the context of HBOT. However, these devices can be expected to harbor unique risks; for example, vacant space in the reservoir of an implanted IDD pump may change in pressure and volume during the compression and decompression phases of HBOT, resulting in a damaged or dysfunctional device. We present the case of a 27-year-old woman with cerebral palsy referred for HBOT to manage a necrotizing soft tissue infection cultured from a dehiscent abdominal wound at the previous implantation site of an intrathecal baclofen pump. An HBOT protocol was ultimately chosen in partnership with the patient and her family, but tre...
Background. Chronic neuropathic pain is a condition affecting an increasing proportion of the gen... more Background. Chronic neuropathic pain is a condition affecting an increasing proportion of the general population and its management requires a comprehensive, multidisciplinary program. A growing body of evidence supports the use of hyperbaric oxygen therapy (HBOT) in several chronic neuropathic pain conditions; however, its role and efficacy remain unclear. Purpose. To summarize current evidence for the mechanistic rationale of HBOT in chronic neuropathic pain conditions and to evaluate its clinical efficacy. Methods. This narrative review was conducted after searching the following databases (Medline, Embase, Cochrane, PsycINFO, the Web of Science, Scopus, ClinicalTrials. gov, WHO ICTRP, and ProQuest Digital Dissertation) from January 1946 to March 2020. Articles published in English that involved either animal or human studies with acute or chronic neuropathic pain evaluating any HBOT-related intervention were included. Results. A total of 2971 citations were identified. A total o...
A systematic review of radiofrequency procedures on innervation to the shoulder joint for relievi... more A systematic review of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain. Accepted for publication in the.
Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bh... more Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bhatia and Vincent Chan gathered studies and guidelines, applied them and mapped the order and structure of the papers. All of the authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.
In the original publication, the legend in the Figure caption were missing and Table was not pres... more In the original publication, the legend in the Figure caption were missing and Table was not presented correctly.
We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative naus... more We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative nausea and vomiting following strabismus repair in children in a hospital-based, prospective, double-blinded, randomized, placebo-controlled trial. Two hundred and ten children were randomized to receive either dexamethasone in one of four dosages: 50 μg/kg (Group 1), 100 μg/kg (Group 2), 200 μg/kg (Group 3) and 250 μg/kg (Group 4) or normal saline (Group 5) prior to corrective surgery for strabismus. Anaesthesia was standardized and included nitrous oxide, pethidine, intubation and the use of muscle relaxant and reversal with neostigmine. Postoperative nausea and vomiting were evaluated in epochs of 0-2 hours, 2-6 hours and 6-24 hours after surgery. Parent satisfaction was assessed 24 hours after surgery and the operated eye was examined for wound infection and delayed healing one week later. Dexamethasone was effective in preventing nausea and vomiting after strabismus repair: 57.1% childr...
Academic medicine : journal of the Association of American Medical Colleges, Jan 24, 2018
Health professions education and practice have seen renewed calls to restore compassion to care. ... more Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways that evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence practitioner and patient experience-based knowledge. This study explored what happens when the discourses of compassionate care and EBP interact in practice. Chronic pain management in Canada was selected as the context for the study. Data collection in 2015-2016 involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis. Four manifestations of the discourse of compa...
Gynecologic and obstetric investigation, Jan 18, 2017
Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There i... more Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There is much ambiguity in diagnostic work-up, appropriate management and decision-making regarding the use of neuraxial analgesia and anaesthesia during labour and delivery in these patients. This systematic review summarises the evidence regarding investigations, management strategies and considerations around performing neuraxial blocks for pregnant women with LBP. We searched 3 databases and reviewed literature concerning LBP in pregnancy with regards to diagnostic modalities, management strategies and use of neuraxial techniques for facilitating labour and delivery. In all, we included 78 studies in this review, with 32 studies concerning diagnostic investigations, 56 studies involving management strategies, and 4 studies regarding the use of neuraxial techniques for labour and delivery. MRI is the safest investigative modality for LBP in pregnancy. Antenatal educational programmes, exerci...
Canadian Association of Radiologists Journal, 2017
Imaging techniques frequently employ contrast agents to improve image resolution and enhance path... more Imaging techniques frequently employ contrast agents to improve image resolution and enhance pathology detection. These gadolinium- and iodine-based media, although generally considered safe, are associated with a number of adverse effects ranging from mild to severe. Reactions are classified as either anaphylactoid (“anaphylaxis-like”) or nonanaphylactoid, depending on a number of elements that will be reviewed. Herein, we have summarized predisposing risk factors for adverse events resulting from the use of contrast, their associated pathophysiological mechanisms as well as known prophylaxis for the antitreatment of high-risk patients. In the unlikely event that a serious adverse reaction does occur, we have provided a comprehensive summary of treatment protocols. Our goal was to thoroughly evaluate the current literature regarding adverse reactions to radiocontrast agents and provide an up to date review for the health care provider.
Purpose Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complicati... more Purpose Stellate (cervicothoracic) ganglion block (SGB) can be associated with serious complications, such as esophageal and vascular injury. The objective of this study was to evaluate the potential for vascular and esophageal injury in healthy subjects by examining the sonoanatomy of the neck relevant to the SGB at the sixth (C6) and seventh (C7) cervical vertebral levels and determining the incidence of blood vessels and esophagi in the simulated path of needle insertion in the conventional and two different ultrasound-guided approaches used to perform a SGB. Methods Ultrasound scanning of the neck at the C6 and C7 cervical vertebral levels was performed in 100 adult subjects, and the following measurements were obtained: the degree of deviation of the esophagus relative to the larynx/trachea; the likelihood of encountering a vessel in This study was conducted with written informed consent from the study subjects. This report describes an observational clinical study, and it adheres to the STROBE guidelines.
Background: Intrathecal morphine is commonly and effectively used for analgesia after joint arthr... more Background: Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty. Methods: This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with lowdose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications. Results: In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m 2 . Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308). Conclusions: Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.
Canadian Medical Association Journal, Sep 30, 2018
Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bh... more Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bhatia and Vincent Chan gathered studies and guidelines, applied them and mapped the order and structure of the papers. All of the authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.
N EUROPATHIC pain is a highly prevalent and often refractory chronic pain condition that is assoc... more N EUROPATHIC pain is a highly prevalent and often refractory chronic pain condition that is associated with substantial disability and deterioration in quality of life. 1 Accumulating evidence suggests that intravenous infusion of ketamine can result in significant relief of refractory neuropathic pain, when the dose is individually titrated to minimize adverse effects and maximize long-term analgesia. 2-5 However, approximately 50% of patients will not respond to this therapy. The factors that contribute to the analgesic effectiveness in some, but not in other patients, are unknown. Here we investigated whether there are noninvasive quantitative sensory testing or measures of brain function that point to aberrant pain mechanisms underlying refractory neuropathic pain that may have prognostic value regarding ketamine treatment. • Ketamine is an N-methyl-D-aspartate antagonist with growing use in the management of chronic pain • Descending pain modulatory circuits are key modulators of chronic pain What This Article Tells Us That Is New • The infusion of ketamine resulted in meaningful pain relief in about 50% of patients with chronic neuropathic pain • The magnitude of temporal summation of pain and the dynamic engagement of the descending pain modulatory circuit predicted treatment efficacy and point to mechanisms by which ketamine can relieve pain
Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has r... more Spinal cord stimulation (SCS) is an established treatment for refractory pain syndromes and has recently been applied to improve locomotion. Several technical challenges are faced by surgeons during SCS lead implantation, particularly in the confined dorsal epidural spaces in patients with spinal degenerative disease, scarring and while targeting challenging structures such as the dorsal root ganglion. Magnetic navigation systems (MNS) represent a novel technology that uses externally placed magnets to precisely steer tethered and untethered devices. This innovation offers several benefits for SCS electrode placement, including enhanced navigation control during tip placement, and the ability to position and reposition the lead in an outpatient setting. Here, we describe the challenges of SCS implant surgery and how MNS can be used to overcome these hurdles. In addition to tethered electrode steering, we discuss the navigation of untethered micro-and nanorobots for wireless and remote neuromodulation. The use of these small-scale devices can potentially change the current standard of practice by omitting the need for electrode and pulse generator implantation or replacement. Open questions include whether small-scale robots can generate an electrical field sufficient to activate neuronal tissue, as well as testing precise navigation, placement, anchoring, and biodegradation of micro-and nanorobots in the in vivo environment.
Background Chronic daily headaches (CDH) are common and associated with significant morbidity, po... more Background Chronic daily headaches (CDH) are common and associated with significant morbidity, poor quality of life, and substantial burden on the healthcare system. CDH tends to be refractory to conventional medical management and/or patients cannot afford expensive treatments. It is stipulated that CDH share a mechanism of central sensitization in the trigeminocervical complex, mediated by activation of the N-methyl-d-aspartate (NMDA) receptors. Ketamine, a non-competitive NMDA antagonist, has been used in the treatment of chronic pain, but its role in CDH has not been completely established. This trial aims to evaluate the effect of high-dose IV ketamine infusions (compared to placebo) on the number of headache days at 28 days post-infusion. Methods A multicenter, placebo-controlled, randomized controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessors. The study will include 56 adults with a CDH diagnosis as per ICHD-3 criteria. Participants will be randomized (1:1) to either ketamine (1 mg. kg -1 bolus followed by infusion of 1 mg. kg -1 . h -1 for 6 h) or placebo (0.9% saline in the same volume and infusion rate as the trial medication) bolus and infusion for 6 h. The impact on the number of monthly headache days, headache intensity, physical activity, mood, sleep, quality of life, analgesic consumption, and adverse effects will be recorded at baseline, immediately post-infusion, and from 1 to 28 days, 29 to 56 days, and 57 to 84 days after the infusion Discussion Despite advancements in treatment, many patients continue to suffer from CDH. This trial investigates whether high-dose IV ketamine infusions can effectively and safely improve the CDH burden as compared to a placebo infusion. This treatment could become a safe, affordable, and widely available option for patients living with refractory headache. Trial registration ClinicalTrials.gov NCT05306899. Registered on
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Apr 1, 2008
Reduced metabolism of morphine can directly and, in combination with encephalopathy (which may re... more Reduced metabolism of morphine can directly and, in combination with encephalopathy (which may result from low residual liver volume), lead to serious, central obtundation. Reduced handling of paracetamol can also lead to exacerbation of potentially compromised liver function. In addition, the surgical stimulus of a large upper abdominal incision with retraction, the resection of sometimes greater than 50% organ volume, and the aim of on-table tracheal extubation, present unique challenges in the provision of adequate analgesia for this type of surgery. Using an intrathecal morphine dose exceeding the dose range of 200-500 µg previously published 2 in combination with a relatively low infusion rate of remifentanil, we observed MAC and opioid-sparing effects, with evidence of adequate analgesia in this particular patient. We did not encounter problems with excessive sedation, respiratory depression, 3 or hyperalgesia. We fully recognize that such a high dose of intrathecal morphine mandates prolonged postoperative monitoring in an appropriate setting. We believe that that this analgesic combination raises a number of interesting clinical points for further investigation and we are currently undertaking a randomized, controlled trial at our centre, to evaluate the efficacy of this technique for patients undergoing major hepatic resection surgery (NCT00553553).
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Dec 4, 2019
Purpose The use of interventional pain management (IPM) modalities to alleviate chronic pain is i... more Purpose The use of interventional pain management (IPM) modalities to alleviate chronic pain is increasing despite the lack of high-quality evidence. We undertook this survey to explore patterns, training, and attributes of IPM practice. Methods We administered a 32-item survey via seven Canadian physician member organizations, whose members were engaged in the management of chronic pain. Results Of 777 physicians contacted, 256 (33%) responded: 45 (6%) declined to participate and 211 (27%) agreed to participate; the number of participants answering any given question varied. One hundred and sixty-nine of 194 (87%) practiced IPM and 103 of 194 (53%) managed only non-cancer pain. Pain management training of C six months was associated with higher odds of IPM training (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.32 to 6.7), but not necessarily ongoing IPM practice (OR, 1.97; 95% CI, 0.74 to 5.3). A substantial percentage of physicians (108 of 168 [64%]) practiced IPM based only on training received during either their base residency program or courses. Only 48 of 186 (26%) felt that there were adequate opportunities for IPM training, and 69 of 186 (37%) believed that their colleagues practiced IPM in accordance with the best current evidence. Conclusions Our survey indicates that IPM practice and training were not uniform, and that interventional therapies for chronic pain may not be performed in accordance with the best available evidence. Our survey highlights a lack of IPM training opportunities, which may result in substandard training. Concerted efforts involving physician organizations and regulators are needed to standardize IPM training and develop clinical guidelines to optimize evidence-based practice.
International Journal of Environmental Research and Public Health
Patients with implanted medical devices are increasingly referred for hyperbaric oxygen therapy (... more Patients with implanted medical devices are increasingly referred for hyperbaric oxygen therapy (HBOT), and the safety of exposing some of these devices to hyperbaric environments has not previously been explored. There is a paucity of evidence surrounding the management of implanted neurological devices such as neurostimulators and intrathecal drug delivery (IDD) pumps in the context of HBOT. However, these devices can be expected to harbor unique risks; for example, vacant space in the reservoir of an implanted IDD pump may change in pressure and volume during the compression and decompression phases of HBOT, resulting in a damaged or dysfunctional device. We present the case of a 27-year-old woman with cerebral palsy referred for HBOT to manage a necrotizing soft tissue infection cultured from a dehiscent abdominal wound at the previous implantation site of an intrathecal baclofen pump. An HBOT protocol was ultimately chosen in partnership with the patient and her family, but tre...
Background. Chronic neuropathic pain is a condition affecting an increasing proportion of the gen... more Background. Chronic neuropathic pain is a condition affecting an increasing proportion of the general population and its management requires a comprehensive, multidisciplinary program. A growing body of evidence supports the use of hyperbaric oxygen therapy (HBOT) in several chronic neuropathic pain conditions; however, its role and efficacy remain unclear. Purpose. To summarize current evidence for the mechanistic rationale of HBOT in chronic neuropathic pain conditions and to evaluate its clinical efficacy. Methods. This narrative review was conducted after searching the following databases (Medline, Embase, Cochrane, PsycINFO, the Web of Science, Scopus, ClinicalTrials. gov, WHO ICTRP, and ProQuest Digital Dissertation) from January 1946 to March 2020. Articles published in English that involved either animal or human studies with acute or chronic neuropathic pain evaluating any HBOT-related intervention were included. Results. A total of 2971 citations were identified. A total o...
A systematic review of radiofrequency procedures on innervation to the shoulder joint for relievi... more A systematic review of radiofrequency procedures on innervation to the shoulder joint for relieving chronic pain. Accepted for publication in the.
Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bh... more Contributors: All authors contributed to the conception, design and drafting of the work. Anuj Bhatia and Vincent Chan gathered studies and guidelines, applied them and mapped the order and structure of the papers. All of the authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.
In the original publication, the legend in the Figure caption were missing and Table was not pres... more In the original publication, the legend in the Figure caption were missing and Table was not presented correctly.
We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative naus... more We studied the efficacy of a range of doses of dexamethasone for prevention of postoperative nausea and vomiting following strabismus repair in children in a hospital-based, prospective, double-blinded, randomized, placebo-controlled trial. Two hundred and ten children were randomized to receive either dexamethasone in one of four dosages: 50 μg/kg (Group 1), 100 μg/kg (Group 2), 200 μg/kg (Group 3) and 250 μg/kg (Group 4) or normal saline (Group 5) prior to corrective surgery for strabismus. Anaesthesia was standardized and included nitrous oxide, pethidine, intubation and the use of muscle relaxant and reversal with neostigmine. Postoperative nausea and vomiting were evaluated in epochs of 0-2 hours, 2-6 hours and 6-24 hours after surgery. Parent satisfaction was assessed 24 hours after surgery and the operated eye was examined for wound infection and delayed healing one week later. Dexamethasone was effective in preventing nausea and vomiting after strabismus repair: 57.1% childr...
Academic medicine : journal of the Association of American Medical Colleges, Jan 24, 2018
Health professions education and practice have seen renewed calls to restore compassion to care. ... more Health professions education and practice have seen renewed calls to restore compassion to care. However, because of the ways that evidence-based practice (EBP) has been implemented in health care, wherein research-based knowledge is privileged, the dominance of EBP may silence practitioner and patient experience-based knowledge. This study explored what happens when the discourses of compassionate care and EBP interact in practice. Chronic pain management in Canada was selected as the context for the study. Data collection in 2015-2016 involved compiling an archive of 458 chronic pain texts, including gray literature from 2009-2015 (non-peer-reviewed sources, e.g., guidelines), patient blog posts from 2013-2015, and transcripts of study interviews with 9 clinicians and postgraduate trainees from local pain clinics from 2015-2016. The archive was analyzed using an interpretive qualitative approach informed by critical discourse analysis. Four manifestations of the discourse of compa...
Gynecologic and obstetric investigation, Jan 18, 2017
Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There i... more Low back pain (LBP) is commonly experienced during pregnancy and is often poorly managed. There is much ambiguity in diagnostic work-up, appropriate management and decision-making regarding the use of neuraxial analgesia and anaesthesia during labour and delivery in these patients. This systematic review summarises the evidence regarding investigations, management strategies and considerations around performing neuraxial blocks for pregnant women with LBP. We searched 3 databases and reviewed literature concerning LBP in pregnancy with regards to diagnostic modalities, management strategies and use of neuraxial techniques for facilitating labour and delivery. In all, we included 78 studies in this review, with 32 studies concerning diagnostic investigations, 56 studies involving management strategies, and 4 studies regarding the use of neuraxial techniques for labour and delivery. MRI is the safest investigative modality for LBP in pregnancy. Antenatal educational programmes, exerci...
Canadian Association of Radiologists Journal, 2017
Imaging techniques frequently employ contrast agents to improve image resolution and enhance path... more Imaging techniques frequently employ contrast agents to improve image resolution and enhance pathology detection. These gadolinium- and iodine-based media, although generally considered safe, are associated with a number of adverse effects ranging from mild to severe. Reactions are classified as either anaphylactoid (“anaphylaxis-like”) or nonanaphylactoid, depending on a number of elements that will be reviewed. Herein, we have summarized predisposing risk factors for adverse events resulting from the use of contrast, their associated pathophysiological mechanisms as well as known prophylaxis for the antitreatment of high-risk patients. In the unlikely event that a serious adverse reaction does occur, we have provided a comprehensive summary of treatment protocols. Our goal was to thoroughly evaluate the current literature regarding adverse reactions to radiocontrast agents and provide an up to date review for the health care provider.
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Papers by Anuj Bhatia