Christoph Diefenbach

Assessment of cancer pain: a prospective evaluation in 2266 cancer patients referred to a pain service

&NA; Although pain assessment is a vital preliminary step towards the satisfactory control of cancer pain, data on the prevalence of different pain syndromes are rare. In a prospective study of 2266 cancer patients, we assessed localisations, aetiologies and pathophysiological mechanisms of the pain syndromes. Thirty percent of the patients presented with 1, 39% with 2 and 31% with 3 or more distinct pain syndromes. The majority of patients had pain caused by cancer (85%) or antineoplastic treatment (17%); 9% had pain related to cancer disease and 9% due to aetiologies unrelated to cancer. Pain could be classified as originating from nociceptors in bone (35%), soft tissue (45%) or visceral structures (33%) or otherwise as of as neuropathic origin (34%). In most patients, pain syndromes were located in the lower back (36%), abdominal region (27%), thoracic region (23%), lower limbs (21%), head (17%) and pelvic region (15%). The main pain syndrome was also coded according to the IASP Classification of Chronic Pain. Regions and systems affected by the main pain syndrome showed large variation depending on the site of cancer origin, whereas temporal characteristics, intensity and aetiology were not markedly influenced by the cancer site. The variety of pain syndromes evaluated in our patients confirms the importance of comprehensive pain assessment prior to treatment.

Prevalence and pattern of symptoms in patients with cancer pain: A prospective evaluation of 1635 cancer patients referred to a pain clinic

In a prospective study, the prevalence of 15 physical symptoms and symptom groups was evaluated in 1635 cancer patients referred to a pain clinic. In addition to pain, patients suffered an average of 3.3 symptoms: insomnia (59%), anorexia (48%), constipation (33%), sweating (28%), nausea (27%), dyspnea (24%), dysphagia (20%), neuropsychiatric symptoms (20%), vomiting (20%), urinary symptoms (14%), dyspepsia (11%), paresis (10%), diarrhea (6%), pruritus (6%), and dermatological symptoms (3%). While symptom prevalence was influenced by tumor site, pain intensity, and opioid treatment, only a minor relationship was seen between symptoms and gender, age, or tumor stage. The data emphasize that it is not sufficient to simply address pain during the treatment of patients with cancer pain; a more global approach to symptom management is necessary.

Large-dose hydroxyethyl starch 130/0.4 does not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with hydroxyethyl starch 200/0.5 at recommended doses.

Background Hydroxyethyl starch (HES) 130/0.4 may impair blood coagulation less than other HES solutions and, thus, may be used at larger doses without increasing the risk of postoperative bleeding. This study tested the hypothesis that volume replacement with 6% HES 130/0.4 at a dose of up to 50 ml/kg does not increase blood loss and transfusion requirements in elective coronary artery bypass surgery compared with 6% HES 200/0.5 at a dose of up to 33 ml/kg. Methods One hundred twenty adult patients scheduled for elective coronary artery bypass surgery were randomized to receive up to 50 ml/kg of 6% HES 130/0.4 or up to 33 ml/kg of 6% HES 200/0.5 for volume replacement during surgery and until 24 h thereafter. Volume requirements in excess of the respective maximum dose of HES were treated with gelatin. Colloid use was at the discretion of the attending physicians and not dictated by protocol. The primary outcome variable was chest tube drainage volume during the first 24 h after surgery. Results The data from 117 patients (HES 130/0.4, 59 patients; HES 200/0.5, 58 patients) who completed the study according to protocol were analyzed. The median volumes of HES administered were 49 and 33 ml/kg in the HES 130/0.4 and HES 200/0.5 groups, respectively (P < 0.001). Consequently, patients in the HES 130/0.4 group required less gelatin in addition to HES than those in the HES 200/0.5 group (medians: 7 ml/kg vs. 20 ml/kg, P < 0.001). The combined volumes of HES and gelatin were similar for both groups (P = 0.21). The 24-h chest tube drainage (medians: 660 ml vs. 705 ml, P = 0.60) did not differ significantly between the groups, nor did transfusion outcome. Conclusion Six percent HES 130/0.4 at a median dose of 49 ml/kg did not increase blood loss and transfusion requirements in coronary artery bypass surgery compared with 6% HES 200/0.5 at a median dose of 33 ml/kg.

Fatal anaphylactic shock after aprotinin reexposure in cardiac surgery.

I n open heart surgery, the administration of aprotinin, a proteinase inhibitor extracted from bovine lung, may achieve a 30%-40% reduction in perioperative blood loss and transfusion requirement (l-3). In contrast to all other blood-saving techniques, the use of aprotinin represents a trespass into the patients’ immunologic memory. This is why in a recent communication we expressed concern about expanding its use in noncardiac procedures (4). We are now presenting the first report on an anaphylactic shock after aprotinin reexposure in open heart surgery where resuscitation was unsuccessful, even with the aid of cardiopulmonary bypass (CPB).

Validation of World Health Organization guidelines for pain relief in head and neck cancer. A prospective study.

In a prospective study of 167 patients with head and neck cancer, we assessed the causes and mechanisms of pain, as well as the efficacy and side effects of analgesic treatment, along World Health Organization (WHO) guidelines. The majority of patients had pain caused by cancer (83%) and/or treatment (28%), 4% had pain due to debility, and 7% had pain unrelated to cancer. Palliative antineoplastic treatment was performed in 32% of patients. Systemic analgesics were administered on 97% of a total of 8,106 treatment days, and coanalgesics or adjuvant drugs on 100%. The treatment proved to be very successful, as severe pain was experienced only during 5% of the observation period. In the absence of serious side effects, the most frequent symptoms observed were insomnia, dysphagia, anorexia, constipation, and nausea. The use of analgesic and adjuvant drugs along WHO guidelines to treat pain in head and neck cancer is highly effective and relatively safe.

Mivacurium: Dose-Response Relationship and Administration by Repeated Injection or Infusion

The dose-response relationship and neuromuscular blockade after infusion or repeated injection of mivacurium were studied in 65 patients in nitrous oxide-narcotic anesthesia. The ED95 (twitch tension) was determined in 45 patients by intravenous injection of a single bolus of 30, 39, 47, 54, or 60 μg/kg (9 patients per dose). Another 20 patients received an initial bolus of 2 × ED95 followed either by an infusion started at 5% twitch recovery (i.e., 95% depression) and adjusted to sustain 95% twitch depression (n = 10) or by repeated injection of 0.6 × ED95 whenever twitch tension had recovered to 25% of control (n = 10). Five patients in each of these two groups received 7 μg/kg of neostigmine at 25% twitch recovery, and the others recovered twitch tension spontaneously. The mean ED95 was 73 μg/kg. A 2 × ED95 bolus was followed by complete twitch depression within 2.2 ± 0.7 min. The mean infusion rate resulted in 6 ± 2 μg · kg−1 ± min−1. The ensuing recovery index was 6 ± 3 min. A 6 ± 2 min recovery index was found after up to 10 repeat injections given every 9 ± 3 min. There was no significant effect of neostigmine in both groups. In conclusion, the recovery indices after the infusion or repeat injection of near-equal doses of mivacurium were identical.

Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement

We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1, comparing it with intravenous patient‐controlled analgesia using piritramide in this prospective, randomised, double‐blind study of 24 ASA physical status I–III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient‐controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 at a rate of 5–9 ml.h−1 and an intravenous patient‐controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient‐controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p < 0.01), and on movement 4 h (p < 0.01) and 8 h (p < 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p < 0.001), especially hypotension (p < 0.01) and vomiting (p < 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p < 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 µg.ml−1 is superior to intravenous opioid by patient‐controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.

Comparison of ondansetron and droperidol in the prevention of nausea and vomiting after inpatient minor gynecologic surgery

Ondansetron and droperidol are both effective in the prevention of postoperative nausea and vomiting (PONV).In this randomized, double-blind study, 80 in-patients scheduled for minor gynecologic surgery received either ondansetron 8 mg intravenously (IV) or droperidol 2.5 mg IV 5 min prior to induction of isoflurane-narcotic anesthesia. PONV was absent in 68% of the patients after ondansetron and in 88% after droperidol (P < 0.05). The respective times of complete arousal from anesthesia were 171 min and 229 min (P < 0.001). After ondansetron and droperidol, the incidence of severe drowsiness, restlessness, anxiety, or dizziness was 5% and 28%, respectively (P < 0.01). Thus after minor gynecologic surgery, droperidol 2.5 mg IV was superior to ondansetron 8 mg IV in the prevention of PONV. However, relative to ondansetron, droperidol entailed an average 1-h delay in recovery from anesthesia. (Anesth Analg 1995;81:603-7)

A comparison of cisatracurium and atracurium : Onset of neuromuscular block after bolus injection and recovery after subsequent infusion

Cisatracurium is a new nondepolarizing muscle relaxant.In patients randomized to receive either cisatracurium (n = 40) or atracurium (n = 20) we compared the time course of neuromuscular block. The initial bolus dose of cisatracurium was 0.1 mg/kg, that of atracurium 0.5 mg/kg. Neuromuscular block, maintained with an infusion of either drug, was reversed with neostigmine 45 micro g/kg and atropine 20 micro g/kg in one half of the patients. Neuromuscular transmission was assessed by recording the mechanical twitch response to train-of-four nerve stimulation. Onset times were 3.1 +/- 1.0 min with cisatracurium and 2.3 +/- 1.1 min with atracurium (P = 0.008). The infusion rates for a 95% +/- 4% neuromuscular block were 1.5 +/- 0.4 micro g [centered dot] kg-1 [centered dot] min-1 for cisatracurium and 6.6 +/- 1.7 micro g [centered dot] kg-1 [centered dot] min-1 for atracurium, 3.3 times those of cisatracurium when referenced to the active cations. After the infusion, the spontaneous recovery intervals 25%-75% of 18 +/- 11 min and 18 +/- 8 min for cisatracurium and atracurium (P = 0.896) were shortened to 5 +/- 2 min and 4 +/- 3 min (P = 0.921) after neostigmine. While attributing different onset times also to differences in the initial doses, we conclude that time profiles for neuromuscular block of both muscle relaxants, when given in equipotent doses, are not different. (Anesth Analg 1996;83:1072-5)

Human Error: The Persisting Risk of Blood Transfusion: A Report of Five Cases

UNLABELLED It is common experience that virus transmission, particularly transmission of the human immunodeficiency virus (HIV), is a principal concern of patients and physicians regarding blood transfusion (1). Many physicians are probably unaware that transfusion-transmitted HIV infection is approximately 50 to 100 times less likely to occur than transfusion error (2-4). This misconception may have been encouraged by the scarcity of reports on transfusion error relative to the tremendous public attention focused on HIV infection. We present five cases illustrating how anesthesiologists, intensivists, and emergency physicians are particularly vulnerable to the risk of administering blood to the wrong recipient. All five cases were collected during a 4-yr period. Transfused units of packed red cells totaled approximately 50,000 U during this period in our department. IMPLICATIONS Human error leading to the transfusion of blood to an unintended recipient is a major source of transfusion-related fatalities. We report five cases that highlight some specific areas in which transfusion error is likely to occur.