Anesthesia _ Neurology _ Chronic Pain
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https://cv.hal.science/maria-dalamagka
https://orcid.org/0000-0001-8703-8770
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How Anesthesiology and Neurology Collaborate in Chronic Pain
| Discipline | Core Focus in Pain Care | Key Interventions & Tools |
|---|---|---|
| Anesthesiology | Nervous system physiology, perioperative modulation, and targeted nerve numbing/blocking | Image-guided nerve blocks, epidurals, radiofrequency ablation, regional anesthesia, and opioid stewardship |
| Neurology | Mapping root causes, peripheral/central nerve pathology, and biomarker identification | Neuromuscular evaluations, anti-epileptic/antidepressant neuro-modulating meds, and spinal cord stimulation |
Palliative care ensure that life remains meaningful
Maria I. Dalamagka
Abstract
Each year an estimated 56.8 million people are in need of palliative care, most of whom live in low- and middle-income countries. For children, 98% of those needing palliative care live in low- and middle-income countries with almost half of them living in Africa. Palliative care is care that provides relief from symptoms resulting from disease or injury. In comparison to curative care, which is meant to cure a disease, palliative care is meant to make the patient more comfortable. The definition of palliative care is "to make a disease or its symptoms less severe or unpleasant without removing the cause." Palliative care will lessen or "palliate" the symptoms and improve your quality of life. Palliative care can help ensure that life remains meaningful and fulfilling despite living with a serious illness. It does this through: practical help, for example, some families may need support with adapting their homes to support a person with a serious health problem; physical care: looking after the needs of the body, through mobility aids and exercises, for instance; medicines: medicines can be used to help with symptoms like pain, vomiting, breathlessness, anxiety, depression and confusion; spiritual support: helping people meet their spiritual needs, such as feeling a sense of belonging, repairing relationships and searching for meaning;emotional support: helping people and their families through the complex emotional challenges of living with a serious illness. Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual. Addressing suffering involves taking care of issues beyond physical symptoms. Palliative care uses a team approach to support patients and their caregivers. This includes addressing practical needs and providing bereavement counselling. It offers a support system to help patients live as actively as possible until death. The goal of palliative care is to relieve suffering and provide the best possible quality of life for patients and their families. Symptoms may include pain, depression, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, and anxiety. The team will help you gain the strength to carry on with daily life. In short, palliative care will help improve your quality of life. Palliative care provides relief in a variety of ways. Physical symptoms such as pain, fatigue, loss of appetite, nausea/vomiting and sleep loss can all be mitigated with palliative approaches, whether through drugs, nutrition, deep breathing, or acupuncture.
Neuro and Radiant oncology and anesthesia considerations
Abstract:
Radiation therapy is a cornerstone treatment for various types of tumors, including those in the nervous system. It uses high-energy rays or particles to destroy or damage cancer cells while attempting to spare surrounding healthy tissues. Depending on the tumor’s location and type, radiation therapy can be broadly applied to larger areas like the brain or precisely targeted at smaller, well-defined tumors using techniques such as stereotactic radiosurgery. Advances in medical technology have made radiation therapy more precise, but some risk to the nervous system remains unavoidable. Head and neck cancer (HNC) is the sixth most common human malignancy with a global incidence of 650,000 cases per year. Radiotherapy (RT) is commonly used as an effective therapy to treat tumours as a definitive or adjuvant treatment. Despite the substantial advances in RT contouring and dosage delivery, patients suffer from various radiation-induced complications. Radiation therapy for nervous system tumors can lead to neurological damage, manifesting as acute, early-delayed, and late-delayed symptoms, with varying degrees of severity and impact on quality of life. The degree of neurological damage depends on factors such as the total radiation dose, the duration of treatment, the dose per session, and individual patient characteristics, including age, genetic predisposition, and overall health. For instance, children are more vulnerable to long-term effects due to the developing nature of their nervous systems, while older adults may face increased risks due to preexisting health conditions. Early-delayed effects typically appear weeks to a few months after the initiation of radiation therapy. These symptoms are generally mild and temporary, including: fatigue; ersisting tiredness, even after rest, can impact daily activities, headaches; recurring headaches may signal ongoing swelling or irritation in the brain, nausea; often linked to the continued healing process or residual swelling. In children undergoing whole-brain radiation, early-delayed symptoms can be more pronounced but often subside over time. Corticosteroids can help manage these symptoms, and physical therapy may be introduced to address any emerging motor coordination issues. Late-delayed effects are the most concerning as they occur months or even years after treatment, potentially causing permanent neurological damage. These effects may include: cognitive decline; issues with memory, attention, and problem-solving abilities, personality changes; mood swings, depression, or reduced emotional resilience, motor coordination problems; difficulty with balance or fine motor tasks, spinal cord damage; radiation near the spine may cause late-delayed myelopathy, resulting in sensory loss, muscle weakness, and Lhermitte sign (a shock-like sensation along the spine when bending the neck forward). Children treated for medulloblastoma or other brain tumors are particularly at risk for these effects due to their higher sensitivity to radiation. Long-term cognitive rehabilitation and regular neurological assessments are essential for managing these complications. Neurologic complications can be seen throughout the course of cancer diagnosis and treatment; some toxicities may not develop for years or even decades after completion of treatment, making diagnosis challenging. However, early recognition is critical as modification of therapeutic regimens can diminish long-term consequences of nervous system injury and improve a patient’s quality of life. Neoadjuvant therapy consisting of either chemotherapy, radiotherapy or immunotherapy is associated with toxic effects on different organ systems. Before surgery, a comprehensive neurological examination should be performed and documented in patients suspected of having neurotoxicity. In patients with peripheral neuropathy, attention should be paid to autonomic dysregulation, as this might lead to orthostatic hypotension. The use of regional anaesthesia is not contraindicated, but pre-existing neurological abnormalities should be documented. Because there is a wide variety of ICIs, the anaesthetist should pay attention to specific agents and toxicities.
Multiple sclerosis an chronic demyelinating disease and anesthesia management
Abstract:
Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system (CNS) and the most common chronic demyelinating disease affecting approximately 2.8 million people worldwide. Its high prevalence worldwide makes it probable for an anesthesia professional to take care of a patient diagnosed with MS at some point during their career. MS is an immune-mediated disease characterized by inflammation, demyelination, and axonal damage in the central nervous system. The course of MS is characterized by exacerbations and remissions at unpredictable intervals over a period of several years. Progression of disability due to MS is highly variable among patients. General, epidural, and spinal anesthesia are generally deemed safe when used in patients with the disease. General anesthesia is the most common anesthetic technique used. There is more controversy surrounding spinal anesthesia, but it seems spinal anesthesia can be administered safely without any additional increased risk of disease relapse. The purpose of the preoperative assessment is to ensure the patient undergoes a safe and adequate anaesthetic experience by selecting the most suitable type of anaesthesia. This assessment must include the full documentation of the neurological deficits detailed by the neurologist in charge of the patient. The use of an established score such as the “Expanded Disability Status Scale” score or “EDSS” score should also be used in order to evaluate the degree of disability. Besides neurological data, the preoperative assessment conducted by the anaesthesiologist should also document any respiratory, cardiac, renal, hepatic, autonomic or any other medical comorbidities. There is a lack of published guidelines on the management of patients with multiple sclerosis (MS) undergoing procedures that require anaesthesia. The anaesthetic management covers preoperative assessment, choice of anaesthetic techniques and agents, side-effects of drugs used during anaesthesia and their potential impact on the disease evolution and drug interactions. The choice of the anaesthetic technique used should be made after careful assessment of the risks and benefits for each specific patient and his preference must also be considered. The association of general anaesthesia and epidural with low concentrations of local anaesthetic are considered safe. Post-operative MS relapses are not affected by the choice of the anaesthetic technique, and that all techniques, including general anaesthesia, may be safely used.
Autoimmune diseases in children and anesthesia
Abstract:
Autoimmune diseases in children may be linked to genetic, environmental, and hormonal factors. It’s estimated that 5% of children worldwide have at least one autoimmune condition, with many experiencing multiple autoimmune challenges. Around 80 autoimmune diseases are present. However, autoimmune diseases in children are rare. When they occur they can be challenging to diagnose and difficult to treat. Advances in our knowledge of the immune system are uncovering connections between inflammation and many different diseases. All autoimmune diseases have relapsing and remitting tendencies. Autoimmune diseases can affect almost any part of the body, though they often target connective tissues (skin, muscle and joints). Symptoms can range from fatigue and mild rashes to rare, serious side effects, like seizures. Diagnosis can be difficult, because many symptoms tend to come and go and are frequently nonspecific. They occur in different kinds of autoimmune diseases as well as other types of illnesses, like infection and cancer. Autoimmune diseases occur most often in females by a 3-to-1 margin over males. Organ-specific disorders (also called localized) focus on one organ or a specific type of tissue: Addison's disease affects the adrenal glands; Autoimmune hepatitis affects the liver; Crohn's disease affects the gastrointestinal tract; Multiple sclerosis (MS) affects the central nervous system; Type 1 diabetes affects the pancreas; Ulcerative colitis affects the gastrointestinal tract. Non-organ-specific disorders (also called systemic) cause problems throughout the body: Juvenile dermatomyositis affects the skin and muscles; Juvenile idiopathic arthritis affects the joints and sometimes the skin and lungs; Lupus affects the joints, skin, liver, kidneys, heart, brain, and other organs; Scleroderma affects the skin, joints, intestine, and sometimes the lungs. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are rare neurobehavioral disorders in children. Affected children may have a diverse array of perioperative manifestations including compulsive behavior, agitation, and abnormal movements. Intravenous anesthetics have anti-inflammatory properties, which in most septic cases are useful for patients. The anti-inflammatory effects of ketamine may be related to the suppression of TNF production by macrophage in the presence of bacteria. Propofol inhibits the phagocytosis and chemotaxis of human monocytes through GABAA receptors. Inhalational anesthetics, in a dose-dependent manner, suppress cytokine release, reduces lymphocyte proliferation, induce apoptosis of the lymphocytes, and inhibits the function of neutrophils. lnhalational anesthetics influence the endocrine response from the hypothalamus-pituitary-adrenal axis and indirectly through the secretions of hormones, such as glucocorticoids and catecholamines. Long-term administration of general anesthesia drugs, due to their effects on cytokines, can lead to disease progression in patients with immune deficiency.
Pediatric neurodegenerative disorders and anesthesia considerations
Maria I. Dalamagka
Pediatric neurodegenerative disorders encompass a wide range of conditions that result from progressive damage to cells and nervous system connections that are essential for mobility, coordination, strength, sensation, and cognition. Neurodegenerative diseases affect millions of people worldwide. Neurological disorders are disorders that involve the brain, spinal cord or nerve and muscle. Children with neurological disorders may have disorders such as epilepsy, developmental delay, cerebral palsy, meningitis, genetic/metabolic diseases or diseases of muscle or nerve such as muscular dystrophy or peripheral neuropathy. These illnesses are frequently severe and potentially have long lasting consequences for the affected children. The pathologies most frequently responsible for psycho-physical disorders can be summarized into three groups: collaboration difficulties (autism spectrum disorders, intellectual impairment, phobia); motor dysfunction (cerebral palsy, epilepsy, other brain pathologies, neuromuscular disorders), and craniofacial anomalies (Down syndrome, other genetic syndromes). Due to their clinical history, and the lack of collaboration, in pediatric non-cooperative patients with Special Needs (SN), the anesthesiological risk may result difficult to assess, despite the fact that they meet the criteria of the outpatient management applied for the patient without disabilities. The perioperative management of pediatric patients with psycho-physical disorders with related relational and cognitive problems must be carefully planned, in order to make the entire hospitalization process as comfortable and as less traumatic as possible. General anesthesia is the most suitable type of anesthesia in pediatric patients with Special Needs (SN), although anesthetic complications are more frequent in these patients, mainly due to comorbidities, taken drugs and anatomical peculiarities. Some studies observed no correlation between multiple anesthesia exposures and neurodevelopmental deficits, while others reported that even a single exposure could increase the risk of deficits. An increased risk of developmental or behavioral disorders as the consequence of surgeries requiring general anesthesia was observed. Based on current studies, it is necessary to endeavor to limit the duration and numbers of anesthesia and the dose of anesthetic agents. The evaluation must include history and physical examination pertaining to the conditions requiring special anaesthetic considerations. Early diagnosis and intervention are crucial in managing these neurological disorders in pediatric patients to improve overall quality of life and long-term outcomes
https://doi.org/10.30574/
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