Cryoablation for Chest Wall Trauma: A Brief Report

Respiratory failure secondary to rib fractures is a major source of morbidity and mortality in trauma patients, particularly in older populations. Management of pain in these patients is complex due to the nature of the injuries. We present 3 patients who underwent a video-assisted thoracoscopic cryoablation of intercostal nerves for pain control after chest trauma. None of the patients developed post-operative complications related to poor respiratory status such as pneumonia or atelectasis. At one-month clinic follow-up, all patients reported no chest pain and were not using opiate analgesics. In patients for whom there is a contraindication to rib fixation in the setting of unstable rib fractures, cryoablation may be a method by which to improve respiratory status and decrease ventilator dependency due to pain. Cryoablation of intercostal nerves may provide a more durable and clinically feasible solution to aid in the healing process of these patients.

Identification of Cytochrome P450 Polymorphisms in Burn Patients and Impact on Fentanyl Pharmacokinetics: A Pilot Study

Pain management is critical for burn care. Unfortunately, interindividual variation in pharmacokinetics (PK) due to burn hypermetabolism and genetic polymorphisms can lead to treatment failures in this at-risk population. Analgesics may be affected by genetic polymorphisms affecting cytochrome P450 (CYP) drug metabolizing enzymes. Fentanyl is a common opiate primarily metabolized by CYP3A4 subtypes. Recent studies demonstrate CYP2D6 variants, affecting fentanyl PK. Functional CYP polymorphisms can significantly alter opiate levels resulting in inadequate analgesia or life-threatening toxicity. The goal of our study was to evaluate fentanyl PK and assess associations with CYP polymorphisms. We obtained samples from the previously banked blood of 13 patients (eight males and five females) with >20% TBSA burns. Mean (SD) patient age was 41.7 (14.5) years, and mean burn size was 25.8 (15.3) %TBSA. Plasma fentanyl was quantified, and CYP genotyping was performed. Pharmacokinetic analysis was performed using Monolix software (Lixsoft, France) with a two-compartment population model best-representing fentanyl profiles. Three CYP slow-metabolizing genotypes were identified, which included CYP2D6*9, CYP2D6*29, and CYP3A4*1B. All three patients with variant polymorphisms had increased serum fentanyl concentrations due to impaired clearance. This pilot study supports the need for further research in this topic, and CYP genotyping of individual patients prior to receiving opiate analgesics to inform precision-guided decisions, improve therapeutic efficacy, and, most importantly, increase patient well-being and safety.

Association of opioid analgesics and sedation with inflammatory markers in critically ill patients: a retrospective descriptive exploratory study

SUMMARYMedical care of critically ill patients is complex and resource intensive. Systemic inflammation is a usual problem among critically ill patients; however, the effects of common medications on inflammation has not been adequately studied.Aim: To explore associations between sedation and opioid analgesics with common inflammatory markers in critically ill patients treated in intensive care units (ICU).Methods: This is a retrospective descriptive correlational study. The study was conducted at the ICU of the biggest Cyprus general hospital and involved all patients hospitalized during the year 2013. Purposive sampling was used. Collection of data was carried out through the ICU electronic data.Results: There is no apparent association of opiate analgesics and suppressants with the CRP.Conclusion: There was no significant association between the use of opiate analgesics and sedatives and inflammatory indicators. There is a need for further research to investigate potential associations between pharmacotherapy and inflammatory markers in critically ill patients giving emphasis on confounding variables, such as patients’ clinical characteristics and severity.