Purpose of Review To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients. Recent Findings A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages. Summary With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.
A 41 year old man presented with pain and numbness affecting the lateral aspect of his foot after a steroid injection for plantar fasciitis. Examination confirmed numbness and motor impairment of the lateral plantar nerve. The findings were confirmed by electromyographic studies. The anatomy of the lateral plantar nerve and correct technique for injection to treat plantar fasciitis are discussed.T he lateral plantar nerve with the medial plantar nerve forms the two terminal divisions of the tibial nerve under the middle of the flexor retinaculum. The lateral plantar nerve crosses the sole obliquely medial to the lateral plantar artery. It supplies flexor accessories and abductor digiti minimi and sends perforating branches through the plantar aponeurosis to supply the skin on the lateral side of the sole. Near the base of the 5th metatarsal bone, it divides into superficial and deep branches (fig 1). The superficial branch supplies the 4th cleft and communicates with the medial plantar nerve and, by a lateral branch, supplies the skin of the lateral side and dorsum of the little toe. The superficial branch supplies three muscles, namely the flexor digiti minimi brevis and the two interossei of the 4th space. The deep branch lies within the concavity of the plantar arch and ends by sinking into the deep surface of the oblique head of adductor hallucis. It gives off branches of the remaining interossei, to the transverse head of adductor hallucis and to the three lateral lumbricals. The first branch of the lateral plantar nerve innervates the region of the medial calcaneal tuberosity, the site of maximal tenderness in plantar fasciitis. CASE HISTORYA 41 year old Iranian man originally presented in August 1999 complaining of pain in his heel consistent with plantar fasciitis. He was prescribed a sorbithane heel cup, and 40 mg Depo-medrone/lignocaine was injected using a medial approach. Over the next three months, the symptoms failed to settle and in fact deteriorated. The patient also complained of numbness in the 3rd, 4th, and 5th toes associated with pain on walking. Examination confirmed the presence of numbness but there was no motor deficit.Nerve conduction studies showed that the lateral plantar sensory nerve action potential was absent on the left but well reproduced on the right. The findings were in keeping with a poorly functioning left lateral plantar nerve and would fit with a history of nerve damage.We reviewed the patient four years after the initial consultation. The symptoms were unchanged, and on examination there was hypoesthesia along the lateral two thirds of the foot, with motor weakness of toe flexion in the 3rd, 4th, and 5th toes.
Ambulatory surgery has gained tremendous popularity within the last 2–3 decades. More and more surgeries are performed on outpatient basis at ambulatory surgery centers. The understanding of how the postanesthesia care unit (PACU) functions is important in the appropriate care and discharge of the patients. Multiple phases of recovery exist and patients can be triaged based on their emergence from anesthesia. PACU discharge scoring systems have been implemented to progress a patient through the stages of recovery until discharge. The scoring systems initially developed by Aldrete, later modified by Chung and White, are still being used today. Discharge from ambulatory surgery centers has unique concerns when compared with discharge from PACU to hospital wards. This chapter will discuss the special considerations when discharging patients from PACU in ambulatory surgery centers.
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