Oguzhan Dagtekin

Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy.

Background: Chronic post‐surgical pain (CPSP) by definition develops for the first time after surgery and is not related to any preoperative pain. Preoperative pain is assumed to be a major risk factor for CPSP. Prospective studies to endorse this assumption are missing.

Risk factors for acute and chronic postoperative pain in patients with benign and malignant renal disease after nephrectomy.

Aims: This longitudinal study was performed in order to analyze the incidence of and perioperative risk factors for the development of chronic postsurgical pain (CPSP) in patients after nephrectomy.

Clinical equivalence of IV paracetamol compared to IV dipyrone for postoperative analgesia after surgery for breast cancer

ABSTRACT Objective: To assess clinical efficacy of IV paracetamol 1 g and IV dipyrone 1 g on a 24.h dosing schedule in this randomised, double-blinded study of 40 ASA I–III (American Society of Anesthesiologists classification of physical status) patients undergoing surgery for breast cancer. Research design and methods: General anaesthesia using remifentanil and propofol was performed for surgery. The patients were randomly allocated to two groups, receiving infusions of paracetamol 1 g/100 mL (Para Group) or of dipyrone 1 g/100 mL (Dipy Group) 30 min before arrival in the recovery area and every 6 h up to 24 h postoperatively. All patients had unrestricted access to opioid rescue medication via an IV patient-controlled analgesia (PCA) device. Main outcome measures: The primary variables for clinical equivalence were the differences between the mean values for pain scores at rest and pain scores on coughing over 30 h postoperatively. The equivalence margin was determined as ±10 mm on the visual analogue scale (VAS). Results: Regarding pain scores at rest, the 90% CI of the mean differences between the treatment groups over 30 h postoperatively was found to be within the predefined equivalence margin [+7.5/–6.2], and the CI values for pain scores on coughing [+7.3/–9.0] were similar. The two groups did not differ in cumulative opioid rescue consumption (Dipy-Group 14.8 ± 17.7 mg vs. Para Group 12.1 ± 8.8 mg, p = 0.54) nor in piritramide loading dose (Dipy Group 0.95 ± 2.8 mg vs. Para Group 1.3 ± 2.8 mg, p = 0.545). Five patients in the Dipy Group experienced hypotension in contrast to none in the Para Group ( p = 0.047). There were no significant between-treatment differences for other adverse events, patient satisfaction scores ( p = 0.4) or quality of recovery scores ( p = 0.3). Conclusion: IV paracetamol 1 g is clinically equivalent to IV dipyrone 1 g for postoperative analgesia after surgery for breast cancer.

Assessing Cognitive and Psychomotor Performance Under Long-Term Treatment with Transdermal Buprenorphine in Chronic Noncancer Pain Patients

BACKGROUND:The therapeutic use of opioids has been associated with altered cognition and impaired psychomotor function. Several studies have demonstrated the impact of opioid therapy on psychomotor performance and cognition, but there are no data about the effect of long-term treatment with transdermal buprenorphine on driving ability. METHODS:Thirty patients suffering from chronic noncancer pain, who had been treated with stable doses of transdermal buprenorphine, included in a prospective trial and compared with 90 healthy volunteers (matched pairs). A computerized test battery, developed to assess the driving ability of traffic delinquents in Germany, was used. Attention reaction, visual orientation, motor coordination, and vigilance were evaluated. The data from 14 variables were assessed, and for each test, a relevant score was defined. As the primary end-point, the sum score of the three relevant scores was determined. A weaker statistical means to assess the patients performance is to compare the test results to an age-independent control group. Individuals performing worse than the 16th percentile of this control group are considered to be unable to drive according to German law. RESULTS:According to tests that predict driving ability, patients receiving transdermal buprenorphine were shown to be noninferior to the control group. Driving ability, as defined as a result above the 16th percentile, did not differ significantly between the patients and the control group. CONCLUSION:Long-term use of transdermal buprenorphine for chronic noncancer pain does not impair driving ability, but because of the individual variability of test results, an individual assessment is recommended.

The Impact of Trendelenburg Position and Positive End-Expiratory Pressure on the Internal Jugular Cross-Sectional Area

BACKGROUND: Increasing the cross-sectional area (CSA) of the right internal jugular vein facilitates cannulation and decreases complications. Maneuvers such as the Trendelenburg tilt position and ventilation with a positive end-expiratory pressure (PEEP) may increase the CSA of the right internal jugular vein. We determined the changes in the CSA in response to different maneuvers. METHODS: The CSA (cm2) of the right internal jugular vein was assessed in 50 anesthetized adult cardiothoracic surgery patients using 2-dimensional ultrasound. First, the CSA was measured in response to supine position with no PEEP (control condition, S0) and compared with 5 different randomly ordered maneuvers: (1) PEEP ventilation with 5 cm H2O (S5), (2) PEEP with 10 cm H2O (S10), (3) a 20° Trendelenburg tilt position with a PEEP of 0 cm H2O (T0), (4) a 20° Trendelenburg tilt position combined with a PEEP of 5 cm H2O (T5), and (5) a 20° Trendelenburg tilt position combined with a PEEP of 10 cm H2O (T10). RESULTS: All maneuvers increased the CSA of the right internal jugular vein with respect to the control condition S0 (all P < 0.05). S5 increased the CSA on average by 15.9%, S10 by 22.3%, T0 by 39.4%, T5 by 38.7%, and T10 by 49.7%. CONCLUSION: In a comparison of the effectiveness of applying different PEEP levels and/or the Trendelenburg tilt position on the CSA of the right internal jugular vein, the Trendelenburg tilt position was most effective.

Prevalence, severity, and chronicity of pain and general health-related quality of life in patients with localized prostate cancer.

Aims: To analyze the prevalence and the severity spectrum of pain and its relationships to health‐related quality of life and the bio‐psycho‐social consequences of pain among patients scheduled for radical prostatectomy.

Chronic pain and disability after pelvic and acetabular fractures--assessment with the Mainz Pain Staging System.

BACKGROUND Chronic posttraumatic pelvic pain (PPP) after pelvic ring fractures impacts negatively on quality of life issues. This study aimed to more clearly identify and quantify the problem. METHODS For this cross-sectional study, patients were examined 52 (median) months after pelvic fractures. The following parameters were measured: pain chronicity (Mainz Pain Staging System [MPSS]), pain intensity (Numeric Rating Scale, 0-10), pelvic fracture outcome scores (Majeed, Pohlemann, and Bürk), pain severity (Chronic Pain Grading Questionnaire), pain-related interference with activities of daily living (Chronic Pain Grading Questionnaire), low back pain-related disability (Oswestry score), neuropathic pain (painDETECT), physical functioning (Short Form-12), and medical comorbidities (Weighted Illness Check List-20). Psychological distress was evaluated for anxiety and depression (Hospital Anxiety and Depression Scale) and mental quality of life (Short Form-12). RESULTS Sixty-nine patients had a total of 49 pelvic and 41 acetabular fractures; 70% underwent osteosynthesis. The prevalence of PPP was 64%. Prevalence weighted with the dysfunctional pain chronicity stages MPSS II and III was 48%. Patients with pelvic fracture types (AO classification) A, B, and C had PPP prevalences of 38%, 67%, and 90%, respectively. Pain chronicity stages (MPSS) were moderately to strongly correlated with pelvic pain intensity (r = 0.57), the three pelvic fracture outcome scores (r = -0.78 to -0.90), pain-related interference (r = 0.72), Oswestry score (r = 0.68), nerve injury and neuropathic pain (r = 0.52), reduced physical (r = -0.72) and mental functioning (r = -0.58), trauma-related comorbidity (r = 0.53), anxiety (r = 0.51), and depression (r = 0.67). CONCLUSION This study demonstrated that the intensity and prevalence of PPP are high even some 4 years after injury. The validated instruments MPSS (measuring pain chronicity) and Oswestry disability score proved to be appropriate for classifying outcome after pelvic ring fractures.

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8h at rest (P=0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P=0.003). No differences were seen in the flap perfusion. Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A does of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.

Haloperidol versus Haloperidol plus Ondansetron for the Prophylaxis of Postoperative Nausea and Vomiting after Ophthalmologic Surgery

Introduction: In this prospective, randomized, and double-blinded study we investigated the efficacy of haloperidol (10 μg/kg) and the combination of haloperidol (10 μg/kg) with ondansetron (0.1 mg/kg) for the prophylaxis of postoperative nausea and vomiting (PONV) after ophthalmologic surgery. Methods: 60 patients (ASA status 1–3) with risk factors for PONV (female, non-smoker, motion sickness or PONV in history, opioids for postoperative analgesia) undergoing retinal or strabismus surgery were included into the study and randomised to the haloperidol group (H-Group) or the haloperidol-ondansetron group (H/O-Group). 20 min before the end of anaesthesia the study medication was given. Nausea, vomiting, pain scores, and adverse events were assessed postoperatively over 24 h. Results: The incidence of PONV was lower for the H/O-Group (23 vs. 57% for the H-Group). Especially the incidence of vomiting was reduced for the H/O-Group (7 vs. 27% in the H-Group). No significant differences could be detected regarding adverse events. Conclusion: The single use of haloperidol for the prophylaxis of PONV is doubtful. Better results were obtained with the combination therapy of haloperidol with ondansetron, especially for vomiting.

Preoperative chronic pain in radical prostatectomy patients: preliminary evidence for enhanced susceptibility to surgically induced pain.

Background and objective The aim of the study was to examine a possible relationship between the extent of preoperative chronic pain and the development of moderate-to-severe acute postoperative pain. Methods Eighty-four patients scheduled for radical prostatectomy were studied. Pain intensities after mobilization during the first 3 postoperative days were added to yield a total pain score (total pain score after mobilization, range 0–30). Pain was considered as moderate to severe at a total pain score after mobilization of 12 or higher. The preoperative severity of chronic pain disorders was measured using the Mainz Pain Staging System (I–III). Further possible preoperative risk factors for the development of intense postoperative pain that were examined included pain intensity, pain in the urological site, psychological distress (Hospital Anxiety and Depression Scale) and health-related quality of life (Short Form-12). Results Patients with moderate-to-severe preoperative chronic pain and those with higher Mainz Pain Staging System stages were significantly (P < 0.001) more likely to develop moderate-to-severe postoperative pain. Anxiety and depression scores as well as physical health (Short Form-12) were significantly associated with a total pain score after mobilization of at least 12. The development of postoperative pain was independent of the presence of preoperative pain in the urological site. Conclusion This study demonstrated that higher degrees of preoperative chronic pain were associated with the development of more intense pain after radical prostatectomy. Preoperative psychological distress and reduced physical health were associated with a marked increase in postoperative pain intensity.