identified several fat-containing concentric compartments. Those compartments were limited by collagen fiber layers that were also similar to the epineurium. Clin.
Somatic and visceral nociceptive signals travel via different pathways to reach the spinal cord. Additionally, signals regulating visceral blood flow and gastrointestinal tract (GIT) motility travel via efferent sympathetic nerves. To offer optimal pain relief and increase GIT motility and blood flow, we should interfere with all these pathways. These include the afferent nerves that travel with the sympathetic trunks, the somatic fibers that innervate the abdominal wall and part of the parietal peritoneum, and the sympathetic efferent fibers. All somatic and visceral afferent neural and sympathetic efferent pathways are effectively blocked by appropriately placed segmental thoracic epidural blocks (TEBs), whereas well-placed truncal fascial plane blocks evidently do not consistently block the afferent visceral neural pathways nor the sympathetic efferent nerves. It is generally accepted that it would be beneficial to counter the effects of the stress response on the GIT, therefore most enhanced recovery after surgery protocols involve TEB. The TEB failure rate, however, can be high, enticing practitioners to resort to truncal fascial plane blocks. In this educational article, we discuss the differences between visceral and somatic pain, their management and the clinical implications of these differences.
Continuous nerve blocks (CNBs), compared with other forms of postoperative analgesia, are less frequently utilized, although postoperative pain control may be improved with their use. Further, it has been demonstrated that the safety and side-effect profiles of opioids and other analgesics are inferior to well-performed CNBs. For CNB success, however, several principles must be adhered to: application of appropriate indications, selection of the correct nerve to block, performance of correct CNB technique, and utilization of correct equipment. Although these are simple concepts, they are often violated and can result in block failure, especially secondary block failure, which occurs once the primary bolus block has worn off. Almost all secondary block failures and medico-legal challenges originate from the violation of ≥1 of these principles. Hilton Law of Anatomy and Fick Law of Diffusion underpin common reasons for CNB failures. In addition, novel developments in our understanding of the macroneuroanatomy and microneuroanatomy may further explain CNB failures.
Summary
Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.