☹️FIBROMYALGIA- AN OVERVIEW 🙍🏻♂️

🦂Is a common chronic pain condition, characterised by 

🖌Pain ( Spontaneous, widespread , diffuse, worse in the morning, hypersensitivity to all painful stimuli, >3 months duration, 11 out of 18 defined tender points produce tenderness on digital palpation)

🖌 Sleep disturbances

🖌 Fatigue 

🦂Pathophysiology may include 

🖌dysfunction of descending inhibitory pathways 

🖌abnormal neurotransmitter release

🖌central sensitisation etc

🦂Tricyclic antidepressants ( like Amitriptyline 5-10 mg ) may be effective in fibromyalgia as they reduce pain & fatigue and improve sleep

🦂Other therapies used:

🖌 Pregabalin

🖌Gabapentin

🖌Newer MAO inhibitors like pirlindole

🖌TENS

🖌Acupuncture 

🖌Intravenous lignocaine

🖌Injection of trigger points

🖌Cognitive Behavioural Therapy

🖌Warm bath

🖌Complimentary therapies

#pain , #fibromyalgia , #PainManagement

Reference: Dedhia JT, Bone ME. Pain and fibromyalgia. Contin Educ Anaesth Crit Care Pain. 2009; 9(5): 162–166.

PIN INDEX AND COLOUR CODING

ANESTHETIC CONCERNS IN TRANS SPHENOIDAL PITUITARY SURGERIES

🐨 Pituitary tumours can be hypo or hyper secretory : so they may exhibit Cushingoid status or cortisol deficiency. Accordingly the anesthetist has to look for diseases which are associated with these conditions

🐨 During the Pre Anesthetic Check up (PAC), we should screen for the presence of factors affecting airway management, like

✔️ Macroglossia

✔️ Soft tissue hypertrophy

✔️Obstructive Sleep Apnea (OSA)

And also for other associations like

✔️ DM

✔️ Systemic Hypertension 

✔️ Ischemic Heart Disease

✔️ Heart failure

✔️ Pulmonary Hypertension 

 🐨 If there is cortisol deficiency ( can be diagnosed by short synacthen test) glucocorticoid supplementation should be continued peri-operatively.

🐨 The trans nasal trans sphenoidal approach offers better visibility and lesser incidence of postoperative Diabetes Insipidus (DI). NB: Both DI and SIADH can occur as postoperative complications; but incidence of DI is much higher (upto 50%) compared to that of SIADH.

🐨Trans nasal surgery requires oro-tracheal intubation, insertion of a throat pack to prevent blood going to trachea and stomach and infiltration of the nasal mucosa with local anesthetic and vasopressor ( by surgeon )

🐨 Establishment of an arterial line will help to intervene promptly during hemodynamic fluctuations that happens with infiltration or intense surgical stimulation 

🐨 Surgeon may request various 'helps' from the anesthesiologist to make the suprasellar part of the tumor prolapse down into the sella, like:

✔️ Insertion of a lumbar drain and letting out of CSF

✔️ Maintenance of hypercapnea (upto 60 mm of Hg)

✔️ Fluid administration

🐨 As the patient is positioned with upper part of trunk and head elevated, there is chance for venous air embolism

🐨 Use of short acting drugs facilitate a rapid and smooth emergence which will help in neurological assessment 

🐨 Presence of blood in pharynx, nasal packs and preexisting OSA, pose additional problems in managing the airway

🐨 We can't apply a nasal CPAP mask in such cases as it can cause pneumocephalus, meningitis and air embolism

Reference: Lim M, Williams D, Maartens N. Anaesthesia for pituitary surgery. J Clin Neurosci. 2006; 13(4): 413–418.