Background Infusion during Intravenous Patient-Controlled Analgesia: The New Routine Analgesia?

Efficacy of vertical infraclavicular plexus block vs. modified axillary plexus block: a prospective, randomized, observer-blinded study.

Background:  Despite containing severe risks, infraclavicular approaches to the brachial plexus gained increasing popularity. Likewise, the vertical infraclavicular plexus block improved anesthesia compared to the standard axillary approach but contains the risk of pneumothorax. Therefore we modified the standard axillary technique by inserting a proximal directed catheter, referred to as a high axillary plexus block. We prospectively compared quality and onset of neural blockade after vertical infraclavicular plexus block (VIP) and high axillary plexus block (HAP) in two randomized groups (30 patients in each). Methods:  In group VIP the insulated needle was inserted midway between the ven…

Opioid tolerance and dependence -- do they matter?

The use of opioids has long been accepted as the standard of care in patients with cancer and acute pain. Opioids can further be used effectively in specific subgroups of patients with chronic nonmalignant pain states. While the development of tolerance and physical dependence are known effects of opioids in cancer and noncancer pain populations, these patients can not be regarded as addicted. However, long-term therapy with short-acting opioids predisposes to tolerance and addiction. Recent research has confirmed the important role of psychopathologic and psychosocial conditions as predictors of failed opioid effectiveness in a significant number of noncancer pain subgroups. The clinical p…

Standardisiertes postoperatives Schmerztherapieschema in der Orthopädie

In order to treat patients with postoperative acute pain effectively, we have developed a standardised algorithm for analgesia. This process includes three levels and the appropriate supply of medication. The therapy level is defined based on the scale of the operation. Accordingly, the prescription and handling of the pain medication is simplified for the attending physician and nurses. The pain level has to be measured by the nursing staff sing a visual analogue scale (VAS). Thus, the efficiency of the analgesics will be continuously evaluated and controlled. The standardised supply medication can be applied in those cases with pain levels > or = 4 (VAS). It is possible to up- or down-gra…

Current practice in regional anaesthesia in Germany

Several new techniques and agents (e.g. ropivacaine) have been introduced in regional anaesthesia to improve patients outcome and safety. The beneficial effects on patient outcome are clear with these techniques, however, no information is available about their pattern and frequency of use in clinical practice. This study presents data concerning the current practice of regional anaesthesia in Germany.A questionnaire was sent to every German anaesthesia department (n = 1381). Questions focused on the frequency and range of regional anaesthetic procedures employed, with attention also to the organizational structural of the individual institution.Six hundred and sixty-seven questionnaires we…

Zwölf Basisregeln der medikamentösen Tumorschmerztherapie

□ Eine erfolgreiche medikamentose Schmerztherapie basiert auf einer sorgfaltigen Schmerzanalyse und Erfassung der Schmerzstarke vor und wahrend der Therapie.

A double blind placebo-controlled study on the rectal administration of morphine as a premedication in abdominal hysterectomy

Abstract Benzodiazepines are now commonly used as anxiolytic premedication prior to surgery. However, the role of opioids, as a premedication, has diminished over the last decades and they are no longer routinely used for premedication. Rather, opioids are generally used to treat severe pain in the postoperative period. Studies have shown that both NSAIDs and opioids improve analgesia in the early postoperative period. Until now, there have been no studies investigating the effect of morphine as a rectal premedication in adults in combination with blood levels of morphine. The effect of a rectal premedication with 30 mg of morphine sulphate, on postoperative pain levels and opioid consumpti…

Epidural ropivacaine -- where are the benefits? A prospective, randomized, double-blind trial in patients with retropubic prostatectomy.

Background:  In comparison with bupivacaine, ropivacaine exhibits comparable anaesthetic effects but with less motor impairment and systemic toxicity. However, the analgesic potency may differ. For example, ropivacaine during obstetric epidural analgesia provides an approximately 40% lower analgesic potency than bupivacaine. Equal visual analogue pain scores require significantly higher dosages of ropivacaine, and general statements about a favourable benefit–risk profile relative to that of bupivacaine may therefore have limited clinical impact. We addressed this topic in a male pain model by evaluating the analgesic efficacy of epidural ropivacaine 0.2% vs. bupivacaine 0.125% after retrop…

Dissatisfaction with post-operative pain management—A prospective analysis of 1071 patients

Summary A total number of 1071 patients was investigated using a modified questionnaire of the American Pain Society to evaluate the pain profile and satisfaction/dissatisfaction on the second post-operative day after different types of surgery (abdominal, traumatic, orthopaedic, urologic, gynaecologic, ENT). Patients were either treated with non-standardized pain management (no measurement of pain intensities, no regular administration of analgesics) (non-APS; n = 575) under responsibility of surgical specialties or with standardized pain management (regular assessment of pain and dose adaptation with i.v. PCA or epidurals) (APS; n = 496) by an anaesthesiology-based acute pain service. Pat…

255 QUANTITATIVE SENSORY TESTING: ASSESSMENT OF THE NEUROPATHIC COMPONENT IN CANCER PAIN

Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery

Background Ketorolac is approved for the relief of postoperative pain but concerns have been raised over a possible risk of serious adverse effects and death. Two regulatory reviews in Europe on the safety of ketorolac found the data were inconclusive and lacked comparison with other non-steroidal anti-inflammatory drugs. The aim of this study was to compare the risk of serious adverse effects with ketorolac vs diclofenac or ketoprofen in adult patients after elective major surgery. Methods This prospective, randomized multicentre trial evaluated the risks of death, increased surgical site bleeding, gastrointestinal bleeding, acute renal failure, and allergic reactions, with ketorolac vs di…

Premature termination of epidural analgesia—A prospective analysis to improve quality

Summary Background and objective Epidural analgesia (EA) is a gold-standard in post-operative pain control. Therefore, modern treatment concepts targeting early patient recovery regularly implement EA. Due to its increasing impact, EA should meet high quality standards in respect to application and maintenance. Though, daily practice often reveals EA-related problems, our investigation aimed to improve EA quality by assessing incidence and reasons of undeliberate, premature termination of post-operative EA. Methods In the first step all patients with post-operative EA were retrospectively studied covering a 6-month period (group 1). We analysed incidences and reasons of undeliberate termina…

Postoperative Schmerztherapie Teil II

Die postoperative Schmerztherapie ist ein relativ neues Feld der operativen Medizin. Fur definierte Patientengruppen und Operationen stehen spezielle Therapieformen zur Verfugung. Starke Schmerzen nach einer Operation unterhalten und verstarken die Stresantwort des Korpers. Sie aktivieren das sympathische Nervensystem und konnen dadurch zu kardiozirkulatorischen Belastungen fuhren. Schmerzen behindern das Durchatmen und Abhusten und konnen dadurch pulmonale Storungen verursachen. Ein Patient mit Schmerzen ist schwieriger zu mobilisieren, die Rehabilitation ist verzogert. Der Einflus der verschiedenen Analgesieverfahren auf den Heilungsprozes wird kontrovers beurteilt. Zumindest bei Patiente…

Cocaine or phenylephrine/lignocaine for nasal fibreoptic intubation?

In order to assess if a mixture of phenylephrine/lignocaine is as effective as cocaine for local analgesia and vasoconstriction during nasal fibreoptic intubation, 99 patients receiving topical nasal analgesia either with cocaine 10% or a mixture of phenylephrine 1% and lignocaine 4% were studied in a randomized double-blind investigation. After topical analgesia a flexible fibreoptic endoscope was advanced through a nostril. Larynx, glottis and trachea were endoscopically sprayed with lignocaine. Following induction of anaesthesia a nasotracheal tube was inserted fibreoptically. Pain intensity and amount of epistaxis during endoscopy were assessed. Blood pressure, heart rate and ECG-ST seg…

Management of incomplete regional anaesthesia in Germany: results of a nation-wide survey.

Background:  Regional anaesthesia (RA) provides well-defined benefits with known attendant risks. However, incomplete blockade may introduce unanticipated risks depending on the compensatory measures employed. Until now, no data were available characterizing the pattern of response of German anaesthesiologists in this situation. This study analyses interventions in response to incomplete RA in a nation-wide setting. Methods:  A questionnaire was sent to every German anaesthesia department (n= 1381). Questions focused on interventions coping with an incomplete RA and differentiated between a pre- and a peri-surgical setting and measures to face pain outside the surgical field. If systemic su…

Chronische Insertions- tendopathie am lateralen Epicondylus humeri

Fragestellung: Seit Beginn der 90er Jahre wurde in der Orthopadischen Universitatsklinik Mainz uberpruft, bei welchen Krankheitsbildern die niederenergetische extrakorporale Stoswellentherapie sinnvoll eingesetzt werden kann. Methode: In einer prospektiv-randomierten Studie wurde die Wirksamkeit der 3maligen Applikation von 1000 vs. 10 Impulsen niedriger Energieflusdichte bei chronischer Epicondylopathia humeri radialis uberpruft. Ergebnisse: Sehr gute oder gute Ergebnisse lagen nach einem Follow-up von 12 Monaten bei 26 von 50 Patienten der Behandlungsgruppe vor, aber lediglich bei 3 der Kontrollgruppe. Schlusfolgerungen: Zusammenfassend last sich sagen, das die Methode bei entsprechender …

Epidurale Analgesie mit Bupivacain-HCl 0,06% plus Fentanyl 0,0002%

Die kontinuierliche epidurale Infusionsanalgesie ist eine effektive Moglichkeit zur Therapie starker postoperativer Schmerzen. Es ist in Deutschland ublich, das geeignete Infusionslosungen unmittelbar vor der Anwendung durch Pflegekrafte zubereitet werden. Der damit verbundene Aufwand wirft logistische und pharmazeutische Probleme auf. Es wird beschrieben, wie in der Apotheke des Universitatsklinikums Mainz Infusionsbeutel zur Mischinfusion von Bupivacain-HCl 0,06% und Fentanyl 0,0002% mit einem Fullvolumen von jeweils 250 ml hergestellt und vorratig gelagert werden. Durch die epidurale Infusion kommt eine ausreichende Analgesie zustande. Zur Untersuchung der physikalisch-chemischen Stabili…

Intraoperative clonidine modulates sympathetic tone in the early postoperative period after remifentanil. A double blind, placebo-controlled study

Abstract Aim of the study : Severe pain following major surgery can impair the control of the cardiovascular system (CVS) by causing sympathetic stimulation, possibly leading to myocardial ischaemia. In this study we examine the influence of intraoperative intravenous (i.v.) clonidine infusion on postoperative analgesia and blood concentrations of noradrenaline and adrenaline after major gynaecological surgery. Methods : All patients underwent an abdominal hysterectomy under balanced general anaesthesia using the new opioid remifentanil. The patients were randomised to receive either 5 μg kg −1 of i.v. clonidine intraoperatively ( n =20), or placebo ( n =20). Over a period of 240 minutes po…

Postoperative Schmerztherapie (Postoperative pain therapy)

Intraoperative wound instillation of ropivacaine extraperitoneally subfascially fails to provide analgesia after remifentanil–isoflurane for abdominal hysterectomy

Summary Background Intraoperative local anaesthetic wound instillation has been shown previously to provide analgesia after abdominal surgery. This pain relief may be important, if remifentanil is used for general anaesthesia, because the rapid offset of action may mean that there is not enough analgesia at the end of surgery and in the recovery period. The aim of this randomized, placebo-controlled, double-blind study was to evaluate the analgesic efficacy of preventative wound instillation of ropivacaine after abdominal hysterectomy (AH). We hypothesized that this approach will significantly reduce postoperative morphine consumption. Patients and methods After ethics approval, 40 patients…

The use of a questionnaire for improvement of postoperative analgesia after transurethral resection of the prostate

Abstract Background : Postoperative analgesic studies with methods like i.v. patient controlled analgesia (i.v. PCA) or epidural analgesia have reported effective pain relief after major surgery, also after urologic cancer surgery. In contrast, systematic results after minor urologic surgery are widely unknown, although the pain intensities may be high for a short time. The aim of the study was to evaluate the usefulness of a pain questionnaire as a measurement tool of postoperative analgesic quality after transurethral resection of the prostate (TUR-P). Methods : A questionnaire of the American Pain Society (APS) for quality assurance of postoperative pain therapy was adapted to estimate t…

The treatment of pain in urology

Contemporary medicine is characterized by sophisticated specialization of the individual physician. The specialist in urological surgery may undertake one of the most important and primary medical tasks, the mitigation and therapy of pain. This review aims to provide an overview of the concepts of pain therapy in urology. Most patients benefit from basic concepts of analgesia, including measuring and documenting pain scores at the bedside by the nursing staff. Patients undergoing very painful operative procedures require more potent techniques of analgesia, e.g. intravenous patient-controlled analgesia and epidural analgesia. These techniques need adequate supervision by an acute pain servi…

Postoperative Schmerztherapie

Intraoperative tramadol reduces shivering but not pain after remifentanil–isoflurane general anaesthesia. A placebo-controlled, double-blind trial

Background and objective Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil–isoflurane-based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil-based general anaesthesia. This randomized, placebo-controlled, double-blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil-based general anaesthesia. Methods After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Su…