Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine

Thirty-eight ASA I-III patients undergoing lower abdominal operations were randomly allocated to receive either morphine (group M, patient-controlled analgesia bolus = 1 mg of morphine) or tramadol (group T, patient-controlled analgesia bolus = 10 mg of tramadol) for post-operative patient-controlled analgesia (PCA) after receiving morphine intraoperatively. There were no between-group differences in the pain, sedation or vomit scores. The nausea scores were significantly higher in group T in the initial 20 h and between 32 and 36 h (P < 0.01, 0-4 and 8-12 h; P < 0.05, 4-8, 12-16, 16-20 and 32-36 h). The incidence of dizziness was also significantly higher in group T (68.4% vs. 31.6%, group T vs. group M, P < 0.05). There was no difference in the overall satisfaction. We conclude that the use of tramadol, compared with morphine, for post-operative PCA after intraoperative loading with morphine is associated with more nausea and dizziness, but with similar sedation, quality of analgesia and patient satisfaction.published_or_final_versio

Reducing perioperative blood loss and allogeneic blood transfusion in patients undergoing major spine surgery

▶ At present, individual techniques, including intraoperative acute normovolemic hemodilution, use of tranexamic acid, use of intrathecal morphine, proper positioning, and modification of operative techniques, seem most promising for reducing perioperative blood loss and allogeneic blood transfusion in patients undergoing major spine surgery. ▶ Other techniques including preoperative autologous predonation; mandatory discontinuation of use of antiplatelet agents; intraoperative and postoperative red-blood-cell salvage; use of aprotinin, epsilon-aminocaproic acid, recombinant factor VIIa, or desmopressin; induced hypotension; avoidance of hypothermia; and minimally invasive operative techniques require additional studies to either establish their effectiveness or address safety considerations. Copyright © 2011 by The Journal of Bone and Joint Surgery, Incorporated.published_or_final_versio

Facilitators and barriers to physical activity following pulmonary rehabilitation in COPD: a systematic review of qualitative studies

Pulmonary rehabilitation has short-term benefits on dyspnea, exercise capacity and quality of life in COPD, but evidence suggests these do not always translate to increased daily physical activity on a patient level. This is attributed to a limited understanding of the determinants of physical activity maintenance following pulmonary rehabilitation. This systematic review of qualitative research was conducted to understand COPD patients’ perceived facilitators and barriers to physical activity following pulmonary rehabilitation. Electronic databases of published data, non-published data, and trial registers were searched to identify qualitative studies (interviews, focus groups) reporting the facilitators and barriers to physical activity following pulmonary rehabilitation for people with COPD. Thematic synthesis of qualitative data was adopted involving line-by-line coding of the findings of the included studies, development of descriptive themes, and generation of analytical themes. Fourteen studies including 167 COPD patients met the inclusion criteria. Seven sub-themes were identified as influential to physical activity following pulmonary rehabilitation. These included: intentions, self-efficacy, feedback of capabilities and improvements, relationship with health care professionals, peer interaction, opportunities following pulmonary rehabilitation and routine. These encapsulated the facilitators and barriers to physical activity following pulmonary rehabilitation and were identified as sub-themes within the three analytical themes, which were beliefs, social support, and the environment. The findings highlight the challenge of promoting physical activity following pulmonary rehabilitation in COPD and provide complementary evidence to aid evaluations of interventions already attempted in this area, but also adds insight into future development of interventions targeting physical activity maintenance in COPD

New Synthetic Thrombin Inhibitors: Molecular Design and Experimental Verification

BACKGROUND: The development of new anticoagulants is an important goal for the improvement of thromboses treatments. OBJECTIVES: The design, synthesis and experimental testing of new safe and effective small molecule direct thrombin inhibitors for intravenous administration. METHODS: Computer-aided molecular design of new thrombin inhibitors was performed using our original docking program SOL, which is based on the genetic algorithm of global energy minimization in the framework of a Merck Molecular Force Field. This program takes into account the effects of solvent. The designed molecules with the best scoring functions (calculated binding energies) were synthesized and their thrombin inhibitory activity evaluated experimentally in vitro using a chromogenic substrate in a buffer system and using a thrombin generation test in isolated plasma and in vivo using the newly developed model of hemodilution-induced hypercoagulation in rats. The acute toxicities of the most promising new thrombin inhibitors were evaluated in mice, and their stabilities in aqueous solutions were measured. RESULTS: New compounds that are both effective direct thrombin inhibitors (the best K(I) was <1 nM) and strong anticoagulants in plasma (an IC(50) in the thrombin generation assay of approximately 100 nM) were discovered. These compounds contain one of the following new residues as the basic fragment: isothiuronium, 4-aminopyridinium, or 2-aminothiazolinium. LD(50) values for the best new inhibitors ranged from 166.7 to >1111.1 mg/kg. A plasma-substituting solution supplemented with one of the new inhibitors prevented hypercoagulation in the rat model of hemodilution-induced hypercoagulation. Activities of the best new inhibitors in physiological saline (1 µM solutions) were stable after sterilization by autoclaving, and the inhibitors remained stable at long-term storage over more than 1.5 years at room temperature and at 4°C. CONCLUSIONS: The high efficacy, stability and low acute toxicity reveal that the inhibitors that were developed may be promising for potential medical applications

Changes in thrombelastograph™ variables associated with aging

Aging is associated with hypercoagulability. To assess thrombelastography (TEG®) variables associated with aging, 132 adult patients of various ages undergoing orthopedic surgery for fracture repair had venous blood samples withdrawn for testing of recalcified TEG® before the induction of anesthesia. Age was weakly correlated with all TEG® variables: r time (R) (r = -0.45, P < 0.001; R = 19.5 - 0.09 × age), k time (K) (r = -0.49, P < 0.001; K = 6.5 - 0.04 × age), maximum amplitude (MA) (r = 0.25, P < 0.01; MA = 53.3 + 0.07 × age), and α (r = 0.52, P < 0.001; α = 52.8 + 0.2 × age). The correlation was stronger for men than for women. Only R was significantly correlated with age when the women were separately analyzed. Part of the correlation may be attributable to a concurrent decrease in hemoglobin with aging, but age remained an independent predictor of R, K, and α on forward stepwise linear multiple regression analysis. Aging was weakly associated with changes in TEG® variables, which should be allowed for when interpreting TEG® measurements in the elderly.link_to_OA_fulltex

Thrombelastographic patterns during cryotherapy for recurrent hepatocellular carcinoma

A cirrhotic patient with recurrent hepatocellular carcinoma and thrombocytopenia undergoing cryotherapy showed: 1) transient hyperfibrinolysis shortly after platelet transfusion, and 2) evidence of activation of coagulation after freezing and thawing of tumor as measured on the thrombelastography. No anti-fibrinolytic treatment was required for the hyperfibrinolysis which subsided spontaneously in this patient. This case report highlights that: 1) in patients with chronic liver disease, platelet transfusion might potentially worsen rather than improve the hemostatic function by activation of fibrinolysis, and 2) activation of coagulation may underlie the perioperative coagulation changes seen in cryotherapy.link_to_subscribed_fulltex

A comparison of postoperative cognitive function and pain relief with fentanyl or tramadol patient-controlled analgesia

Study Objective: The use of different opioids for patient-controlled analgesia (PCA) may affect postoperative cognitive function differently. Patient-controlled analgesia fentanyl has been shown to preserve cognitive function better than morphine. The effect of PCA tramadol on cognitive function is unknown. This study aims to compare postoperative cognitive function and analgesia of PCA fentanyl or tramadol. Design: Prospective randomized double-blinded study. Setting: Metropolitan teaching hospital. Patients: 30 ASA physical status I, II, and III patients undergoing lower abdominal operations. Interventions: Patients received standard general anesthesia for their operations. Postoperatively, patients received either fentanyl (group F, 10 μg bolus, n = 17) or tramadol (group T, 20 mg bolus, n = 13) for PCA. Group F patients also received fentanyl boluses and group T patients received tramadol boluses intraoperatively. Measurements: Cognitive function was measured using Mini-Mental State Examination and Benton Visual Retention Test (BVRT) preoperatively and on days 1 and 2. Pain was measured by numerical rating scale. Results: No differences were found in postoperative Mini-Mental State Examination or BVRT scores, but significantly fewer (29.4%; 95% confidence interval [CI], 13.3%-53.1%) group F patients were able to complete BVRT compared with group T patients (84.6%; 95% CI, 57.8%-95.7%; 95% CI of difference, 19.4%-74.8%) (P = 0.010) on day 1. In the first 24 hours, group F and group T patients had similar analgesia at rest, but group T patients had better analgesia during cough (mean Numeric Rating Scale, 7.6; 95% CI, 7.0-8.2 vs 6.0; 95% CI, 4.8-7.2, group F vs group T) (P = 0.018; 95% CI of difference, 0.4-2.8). No differences were found in frequency of side effects or patient satisfaction. Conclusions: Tramadol or fentanyl PCA has similar cognitive effects on days 1 and 2; however, patients receiving tramadol PCA are more motivated to undergo cognitively demanding tasks and have slightly better analgesia on postoperative day 1. © 2006 Elsevier Inc. All rights reserved.link_to_subscribed_fulltex

The bamboo skewer: Airway management in a patient with penetrating injury of the floor of mouth

Purpose: To report a safe airway management option in patients with penetrating injury of the floor of the mouth, reinforcing the similar experience of others and illustrating the importance of proper assessment and planning before airway negotiation. Clinical features: A 23-yr-old man was admitted with a penetrating injury of the floor of mouth caused by falling on bamboo and with the foreign body in situ. The extent of penetration could not be assessed clinically but computerized tomography (CT) was used to assist in preoperative evaluation of the airway. After atropine iv, fentanyl iv, topical cocaine and lidocaine spray, awake fibreoptic guided nasal intubation was performed successfully and the patient's airway secured before induction of anaesthesia. Elective tracheostomy was performed postoperatively which was removed on day 5. Postoperative recovery was uneventful. Conclusion: Awake fibreoptic guided nasal intubation was useful in managing the airway of a patient with a penetrating injury of the floor of mouth and foreign body in situ. Thorough previous evaluation of the patient's airway by CT scan, careful topicalisation of the airway, and judicious use of iv sedation and anti-sialogue contributed to the safe and successful airway management.link_to_subscribed_fulltex

The role of Desmopressin in a patient with severe coagulopathy aggravated by mild therapeutic hypothermia

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Adjuvant analgesics in acute pain

Introduction: Despite its central role in acute pain management, the exclusive use of opioids has been challenged recently in view of its immediate and long-term side effects. Development of chronic postsurgical pain syndromes, hyperalgesia and immunomodulation are some particular concerns as they may be related to opioid exposure, intertwined with patient characteristics and other factors. Application of a multimodal approach, administration of preventive analgesia and paradigm shift in surgical techniques all mandate a revisit of evidence-based perioperative pain management. Areas covered: Adjuvant analgesics are drugs indicated for primary non-pain conditions, but have been found efficacious in analgesia either when used alone or in combination with other analgesics. Among a diverse group of adjuvant analgesics, systemic administration of ketamine, magnesium, gabapentinoids, steroids, α2 agonists and lidocaine are reviewed, with recent evidence compared with earlier systematic reviews or meta-analyses from a Medline search (1990-Apr 2010). Expert opinion: For acute pain management, adjuvant analgesics in appropriate doses and monitored care are beneficial in improving analgesic efficacy and reduce opioid-related side effects with good safety and tolerability. However, the quest for an optimal regime for administration and individualizing treatment remains. © 2011 Informa UK, Ltd.link_to_subscribed_fulltex