The concept of objective nociceptive assessment and optimal pain management have gained increasing attention. Despite the known negative short- and long-term consequences of unresolved pain or excessive analgosedation, adequate nociceptive monitoring remains challenging in non-communicative, critically ill adults. In the intensive care unit (ICU), routine nociceptive evaluation is carried out by the attending nurse using the Behavior Pain Scale (BPS) in mechanically ventilated patients. This assessment is limited by medication use (e.g., neuromuscular blocking agents) and the inherent subjective character of nociceptive evaluation by third parties. Here, we describe the use of two nociceptive reflex testing devices as tools for objective pain evaluation: the pupillary dilation reflex (PDR) and nociception flexion reflex (NFR). These measurement tools are non-invasive and well tolerated, providing clinicians and researchers with objective information regarding two different nociceptive processing pathways: (1) the pain-related autonomic reactivity and (2) the ascending component of the somatosensory system. The use of PDR and NFR measurements are currently limited to specialized pain clinics and research institutions because of impressions that these are technically demanding or time-consuming procedures, or even because of a lack of knowledge regarding their existence. By focusing on the two abovementioned nociceptive reflex assessments, this study evaluated their feasibility as a physiological pain measurement method in daily practice. Pursuing novel technologies for evaluating the analgesia level in unconscious patients may further improve individual pharmacological treatment and patient related outcome measures. Therefore, future research must include large well-designed clinical trials in a real-life environment.

More than 15 years have elapsed since the publication of major studies that clearly demonstrated the benefit of aggressive glycaemic control in persons with diabetes.1-3 Currently, frequent self-monitoring of blood glucose (SMBG) is required to achieve tight glycaemic control. 4 However, SMBG does not provide information about the direction, magnitude, duration, frequency and causes of fluctuations in blood glucose values. Moreover, the fear of hypoglycaemia has a significant impact on patient quality of life and therefore remains a major barrier to achieving optimal glycaemic control. Whereas SMBG takes only a snapshot, continuous glucose monitoring (CGM) provides a complete motion picture of glucose values throughout the day. [5][6][7] In this way CGM, may prove to be an important asset in future diabetes care. This review addresses advantages and limitations of CGM and the target population. Advantages of Continuous Glucose Monitoring Metabolic ControlCGM systems provide the patient and the treating physician with a complete picture of glucose levels throughout the day. They can be used either as a Holter system (retrospectively) or as a realtime monitor. 5-8 CGM readings may facilitate the making of specific therapeutic adjustments to improve metabolic control. These adjustments can be based either on retrospective analysis and pattern recognition or on realtime data verified by SMBG. It will also be possible to take preventative measures by warning the patient against impending hypo-and hyperglycaemic excursions. 8,9A number of non-randomised, uncontrolled trials have documented improvement of glycated haemoglobin (HbA 1c ) and glycaemic excursions (see Table 1). [10][11][12][13][14][15][16][17][18][19] A total of 13 randomised controlled trials (RCTs) of CGM on metabolic control have been published to date (see Table 1). [20][21][22][23][24][25][26][27][28][29][30][31][32] In 12 RCTs, HbA 1c was used as the primary end-point. SevenRCTs used CGM in retrospect and only one study showed improvement Clinical Aspects of Continuous Glucose Monitoring CGM can also be applied to identify and treat post-prandial hyper-glycaemia. 35 Post-prandial glucose peaks vary according to meal composition, so the timing of insulin administration has to be optimal.Factors that patients need to take into account before taking extra insulin to treat post-prandial hyperglycaemia include the residual insulin 'on board' from the pre-meal bolus, the direction of the glycaemic trend and the type of carbohydrate in the meal. In the recently published JDRF trial, hypoglycaemic events were infrequent in the two study groups. Only 5-10% of patients experienced at least one severe hypoglycaemic event, with no significant difference between the study groups. Despite this, it is noteworthy that in the CGM group among patients 25 years of age or older a decrease in HbA 1c levels was achieved without an increase in hypoglycaemic episodes. This finding is in contrast to those of the Diabetes Control and Complication Trial, which showed an inc...

Percutaneous epidural adhesiolysis (PEA) is a minimal invasive procedure to relieve sciatalgia caused by post lumbar surgery syndrome (PLSS). Fluoroscopic-guided contrast-epidurography is essential to ensure a safe procedure. We present a case of a 28-year-old male patient who underwent a PEA which was complicated by a dural puncture. We highlight the dangers of such complications and discuss associated risk factors.

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