Interventional pain management during SARS-CoV-2 pandemic

Background: SARS-CoV-2 virus resulted in a sudden dreadful outbreak, posing a serious global public health problem consuming most of the healthcare resources. Requirement to allocate the existing resources for SARS-CoV-2 management during the pandemic has led to significant challenges in pain management as well as in other healthcare services.

Objectives: This study aimed to report the outcomes of an interventional pain management unit of a COVID-free hospital, where a fraction of medical services is being provided through telemedicine, and where patients and healthcare workers are screened periodically, in addition to the implementation of guideline-recommended key precautions.

Study design: Retrospective chart review.

Setting: Pain clinic of a private COVID-free hospital.

Methods: A total of 83 patients asymptomatic for SARS-CoV-2 and scheduled for interventional pain management (epidural injection, epidural neuroplasty, peripheral nerve and sympathetic ganglion block, and radiofrequency interventions for non-malignant pain; celiac-splanchnic impar ganglion neurolysis and epidural-spinal port catheter implantation for malignant pain) were screened using reverse transcriptase polymerase chain reaction (RT PCR), Immunoglobulin G and Immunoglobulin M antibodies, and computerized tomography (CT) imaging prior to the intervention and were then followed-up for a minimum duration of 30 days. All healthcare workers of the hospital as well as the staff in the pain management center were monitored with RT-PCR tests performed every 5 days. The efficacy of pain management interventions was assessed using a 10-point visual analogue scale (VAS), while a 5-point post-intervention questionnaire was used to measure the patient satisfaction regarding telemedicine practices, where 5 indicates maximum satisfaction.

Results: Patients were finally diagnosed as follows: 2 (2.4%) patients, PCR-confirmed SARS-CoV-2 infection; 3 (3.6%) patients, previous SARS-CoV-2 infection; 13 (15.7%) patients, suspected SARS-CoV-2 infection; and 65 (78.3%) patients, no SARS-CoV-2 infection. Three out of the 517 healthcare workers (0.6%) had PCR positivity in routine screening performed throughout the study, and all these three subjects were asymptomatic. Following interventional treatment, VAS scores were significantly reduced at 2 weeks when compared to baseline (3.9 ± 1.3 vs. 8.6 ± 1.0, P < 0.001), and this reduction was maintained until month 1. Mean satisfaction scores for the communication with the physician using telemedicine methods and for the follow-up management using telemedicine methods were 3.0 ± 0.9 and 3.7 ± 0.6, respectively. None of the patients had steroid-related side effects and none developed new-onset SARS-Cov-2 confirmed or suspected infection throughout the study.

Limitations: Retrospective design and relatively small sample size.

Conclusion: Our findings suggest that effective diagnostic tests/imaging studies aimed at detecting infected patients and healthcare workers, and telemedicine practices contribute to the provision of safe and feasible pain management practices during the SARS-CoV-2 pandemic.

SARS-CoV-2; COVID-19; Pandemic; Pain management; Interventional pain manage-ment

[1] Nandi S, Kumar M, Saxena M, Saxena AK. The antiviral and antimalarial drug repurposing in quest of chemotherapeutics to combat COVID-19 utilizing structure-based molecular docking. Combinatorial Chemistry & High Throughput Screening. 2020; 23.

[2] Disease GBD, Injury I, Prevalence C. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. 2017; 390: 1211-1259.

[3] Brennan F, Carr D, Cousins M. Access to Pain Management—still very much a Human Right. Pain Medicine. 2016; 17: 1785-1789.

[4] Jukic M, Puljak L. Legal and ethical aspects of pain management. Acta Medica Academica. 2018; 47: 18-26.

[5] Shanthanna H, Cohen SP, Strand N, Lobo C, Eldabe S, Bhatia

A, et al. Recommendations on chronic pain practice during the COVID-19 pandemic: a joint statement by American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA). 2020. Avail-able at: https://www.asra.com/page/2903/recommendations-on-chronic-pain-practice-during-the-covid-19-pandemic.

[6] Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, Lynch ME, et al. Managing patients with chronic pain during the COVID-19 outbreak. Pain. 2020; 161: 889-893.

[7] Shanthanna H, Strand NH, Provenzano DA, Lobo CA, Eldabe S, Bhatia A, et al. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia. 2020; 75: 935-944.

[8] Al-Sadeq DW, Nasrallah GK. The incidence of the novel coronavirus SARS-CoV-2 among asymptomatic patients: a systematic review. International Journal of Infectious Diseases. 2020; 98: 372-380.

[9] Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020; 296: E32-E40.

[10] Nikolai LA, Meyer CG, Kremsner PG, Velavan TP. Asymptomatic SARS coronavirus 2 infection: Invisible yet invincible. International Journal of Infectious Diseases. 2020; 100: 112-116.

[11] Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine. 2020; 382: 1679-1681.

[12] Prokop M, van Everdingen W, van Rees Vellinga T, Quarles van Ufford H, Stöger L, Beenen L, et al. CO-RADS: a categorical CT assessment scheme for patients suspected of having COVID-19-definition and evaluation. Radiology. 2020; 296: E97-E104.

[13] Huybens EM, Bus MPA, Massaad RA, Wijers L, van der Voet JA, Delfos NM, et al. What is the preferred screening tool for COVID-19 in asymptomatic patients undergoing a surgical or diagnostic procedure?World Journal of Surgery. 2020; 44: 3199-3206.

[14] Singer JS, Cheng EM, Murad DA, de St. Maurice A, Hines OJ, Uslan DZ, et al. Low prevalence (0.13%) of COVID-19 infection in asymptomatic pre-operative/pre-procedure patients at a large, academic medical center informs approaches to perioperative care. Surgery. 2020; 168: 980-986.

[15] Tanacan A, Erol SA, Turgay B, Anuk AT, Secen EI, Yegin GF, et al. The rate of SARS-CoV-2 positivity in asymptomatic pregnant women admitted to hospital for delivery: Experience of a pandemic center in Turkey. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020; 253: 31-34.

[16] Mays J, Greninger A, Jerome K, Lynch J, Mathias P. Pre-procedural surveillance testing for SARS-CoV-2 in an asymptomatic population in the seattle region shows low rates of positivity. Journal of Clinical Microbiology. 2020; 58: e01193-20.

[17] Sutton D, Fuchs K, D’Alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. New England Journal of Medicine. 2020; 382: 2163-2164.

[18] Trowbridge S, Wignadasan W, Davenport D, Sarker S, Hunter A, Gidwani S. Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma during the COVID-19 pandemic. Journal of Clinical Orthopaedics and Trauma. 2020; 11: S700-S703.

[19] Cárdenas-Camarena L, Bayter-Marin JE, Durán H, Hoyos A, López-Romero CO, Robles-Cervantes JA, et al. Elective surgery during SARS-Cov-2/Covid-19 pandemic. Plastic and Reconstructive Surgery-Global Open. 2020; 8: e2973.

[20] Gammeri E, Cillo GM, Sunthareswaran R, Magro T. Is a “COVID-19-free” hospital the answer to resuming elective surgery during the current pandemic? Results from the first available prospective study. Surgery. 2020; 168: 572-577.

[21] Hunter E, Price DA, Murphy E, van der Loeff IS, Baker KF, Lendrem D, et al. First experience of COVID-19 screening of health-care workers in England. the Lancet. 2020; 395: e77-e78.

[22] [COVID-19 with all aspects], Turkish Thoracic Society, COVID-19 e-book series, June 2020, ISBN: 978-605-06717-1-1. Avail-able at: https://toraks.org.tr/site/community/downloads/nDQxie_Cxq8IOotq (Accessed: 8 January 2021).

[23] Kantele A, Lääveri T, Kareinen L, Pakkanen SH, Blomgren K, Mero S, et al. SARS-CoV-2 infections among healthcare workers at Helsinki University Hospital, Finland, spring 2020: Serosurvey, symptoms and risk factors. Travel Medicine and Infectious Disease. 2021; 39: 101949.

[24] Rivett L, Sridhar S, Sparkes D, Routledge M, Jones NK, Forrest S, et al. Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission. Elife. 2020; 9: e58728.

[25] COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. 2020; 396: 27-38.

[26] World Health Organization. Global surveillance for COVID-19 caused by human infection with COVID-19 virus: interim guidance. 2020.

[27] Zhang W, Du R, Li B, Zheng X, Yang X, Hu B, et al. Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes. Emerging Microbes & Infections. 2020; 9: 386-389.

[28] Rondanelli M, Faliva MA, Miccono A, Naso M, Nichetti M, Riva A, et al. Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents. Nutrition Research Reviews. 2018; 31: 131-151.

[29] Rautiainen S, Levitan EB, Orsini N, Åkesson A, Morgenstern R, Mittleman MA, et al. Total antioxidant capacity from diet and risk of myocardial infarction: a prospective cohort of women. The American Journal of Medicine. 2012; 125: 974-980.

[30] Memari A, Shariat A, Anastasio AT. Rising incidence of musculoskeletal discomfort in the wake of the COVID-19 crisis. Work. 2020; 66: 751-753.

[31] Shariat A, Anastasio AT, Soheili S, Rostad M. Home-based fundamental approach to alleviate low back pain using myofascial release, stretching, and spinal musculature strengthening during the COVID-19 pandemic. Work. 2020; 67: 11-19.

[32] Dario AB, Moreti Cabral A, Almeida L, Ferreira ML, Refshauge K, Simic M, et al. Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis. The Spine Journal. 2017; 17: 1342-1351.

[33] Badalato GM, Kaag M, Lee R, Vora A, Burnett A. Role of telemedicine in urology: contemporary practice patterns and future directions. Urology Practice. 2020; 7: 122-126.

[34] Moo LR, Gately ME, Jafri Z, Shirk SD. Home-based video telemedicine for dementia management. Clinical Gerontologist. 2020; 43: 193-203.

[35] O’Brien KM, Hodder RK, Wiggers J, Williams A, Campbell E, Wolfenden L, et al. Effectiveness of telephone-based interventions for managing osteoarthritis and spinal pain: a systematic review and meta-analysis. PeerJ. 2018; 6: e5846.

[36] Kruse CS, Krowski N, Rodriguez B, Tran L, Vela J, Brooks M. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open. 2017; 7: e016242.

[37] Lurie N, Carr BG. The role of telehealth in the medical response to disasters. JAMA Internal Medicine. 2018; 178: 745-746.

[38] Hjelm NM. Benefits and drawbacks of telemedicine. Journal of Telemedicine and Telecare. 2005; 11: 60-70.

[39] Schlumberger HD, Schrinner E. “We have a high research potential”. Prof. Dr. med. H. D. Schlumberger, Bayer, and Dr. E. Schrinner, Hoechst, interpret the cooperation of both companies in AIDS research. Interview by T. U. Keil. Fortschritte der Medizin. 1988; 106: 22-23. (In German)

[40] Plein LM, Rittner HL. Opioids and the immune system-friend or foe. British Journal of Pharmacology. 2018; 175: 2717-2725.

[41] Dublin S, Walker RL, Jackson ML, Nelson JC, Weiss NS, Korff M, et al. Use of opioids or benzodiazepines and risk of pneumonia in older adults: a population-based case-control study. Journal of the American Geriatrics Society. 2011; 59: 1899-1907.

[42] Page GG. Immunologic effects of opioids in the presence or absence of pain. Journal of Pain and Symptom Management. 2005; 29: 25-31.

[43] Kim S, Hong S, Yun S, Choi W, Ahn J, Lee YJ, et al. Corticosteroid treatment in critically ill patients with pandemic influenza a/H1N1 2009 infection. American Journal of Respiratory and Critical Care Medicine. 2011; 183: 1207-1214.

[44] Cohen SP, Baber ZB, Buvanendran A, McLean BC, Chen Y, Hooten WM, et al. Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Medicine. 2020; 21: 1331-1346.

[45] Liu J, Zheng X, Huang Y, Shan H, Huang J. Successful use of methylprednisolone for treating severe COVID-19. Journal of Allergy and Clinical Immunology. 2020; 146: 325-327.

[46] World Health Organization. Corticosteroids for COVID-19. Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-Corticosteroids-2020.1 (Accessed: 8 January 2021).