Persistent post-partum pain after vaginal birth and cesarean section

Purpose of review: Labor pain remains under evaluated and under managed while evidence is growing that post partum treatments strongly influence patients’ outcome. The present review examines the recent developments in mechanisms underlying labor and delivery pain and questions current understanding of post-partum pain features observed in patients. Recent findings: Different strategies to approach acute labor pain have been developed. Chronic pain after labor and delivery has not been studied so extensively. Prevalence rates of chronic pain after cesarean section are between 6 and 18% and after vaginal delivery they are between 4 and 10%. Predictors for chronic pain after cesarean section and delivery are previous chronic pain, general anesthesia and higher post delivery pain. As labor pain is rated as one of the most serious kinds of acute pain we speculate that effective treatment of this pain with peripartum epidural analgesia could prevent the development of chronic pain. Conclusion: Treatment of acute pain during labor and delivery is necessary to prevent chronic pain. Effective perioperative block of nociceptive inputs from the wound as well as use of antihyperalgesic and analgesic drugs in combination seem the best way to control postoperative pain and specifically to prevent central sensitization. Future studies should focus on the long-term effects of different analgesic regimens on the development of chronic pain after labor and delivery

Pro i kontra za adjuvanse u neuraksijalnoj anesteziji i perifernim blokovima živaca

Modern approach in surgical treatment and in managing acute and chronic pain is nowadays more and more based on the implementation of all possible techniques of regional anesthesia (RA). Local anesthetics (LA) are needed to achieve standard regional anesthesia. Local anesthetics are primarily characterized by time constraints and duration of action, and depending on the amount applied, adverse effects on the cardiac and central nervous system may occur. Adjuvants are drugs used together with LA due to their synergistic effect, i.e. they improve start latency and duration of sensory and motor blockade and enable reduction of cumulative dose of LA and reduction of adverse effects on cardiac and nervous system. Nowadays, there is a huge variety of drugs that can be administered in combination with LA, and they, in general, can be divided into opioid and non-opioid adjuvants. The administration of opioids in RA over an extended time period was accompanied by some negative characteristics as respiratory depression, nausea, vomiting. So, their usage is still under a special control. Due to the positive effects shown by drugs from non-opioid adjuvants group (e.g. adrenaline, alpha adrenergic agonists, steroids, magnesium, midazolam, ketamine etc.), indications for their administration broadened. However, there are still some restrains in clinical practice based on the fact that neurotoxicity and demonstration of neurological complications in regional anesthesia haven’t been properly researched yet.Suvremeni pristup u kirurškom liječenju te u liječenju akutne i kronične boli danas se sve više temelji na primjeni raznovrsnih tehnika regionalne anestezije (RA). Lokalni anestetici (LA ) su zlatni standard u ostvarivanju regionalne anestezije. Lokalne anestetike prvenstveno karakterizira vremenski definirano trajanje učinka, a ovisno o primijenjenoj količini uvijek postoji mogučnost pojave štetnih učinaka na srčani i središnji živčani sustav. Adjuvansi su lijekovi koji se kombiniraju sa LA zbog njihovog sinergističkog učinka, odnosno poboljšavaju početnu latenciju i trajanje senzoričke i motoričke blokade te omogućuju smanjenje kumulativne doze LA i smanjenje štetnih učinaka na srčani i živčani sustav.Danas postoji veliki izbor lijekova koji se mogu davati u kombinaciji s LA, a općenito se mogu podijeliti na opioidne i neopioidne pomoćne tvari. Primjena opioida u RA tijekom duljeg vremenskog razdoblja bila je popraćena nekim negativnim karakteristikama kao što su respiratorna depresija, mučnina, povraćanje, pa je njihova primjena i dalje pod posebnim nadzorom. Indikacije za primjenu lijekova iz skupine neopioidnih pomoćnih tvari (npr. adrenalin, alfa adrenergički agonisti, steroidi, magnezij, midazolam, ketamin itd.) su se zbog njihovih pozitivnih učinaka sve više proširile. Međutim, u kliničkoj praksi još uvijek postoji određena suzdržanost o njihovoj primjeni a na temelju činjenice da još uvijek nije dovoljno istražena njihova neurotoksičnost, odnosno nije definirana njihova uloga u pojavi neuroloških komplikacija u tijeku regionalne anestezije

Unilateral spinal anesthesia with low dose bupivacaine and ropivacaine: hypobaric or hyperbaric solutions with fentanyl for one-day surgery?

Background and Objectives: The purpose of this study was to compare the quality of unilateral spinal anesthesia with low dose bupivacaine and ropivacaine deluded in different baric solutions (hyperbaric / hypobaric). In our special interest was to define possibilities to use hypobaric solutions of local anesthetics if they prove to have any advantages. Methods: This prospective study was conduced over a 24-month period, enrolling eighty patients (ASA groups I, II, III) randomly divided into four groups. The study solution [5mg of o.5% bupivacaine or 5 mg 1.0% ropivacaine with 25/mikron/ g fentanyl, prepared in a different baric solution (hyperbaric / hypobaric)] were injected into the subarachnoidal interspaces at the level L2-L3/L3-L4. After the inducing spinal anesthesia, the patients in the hyperbaric groups kept the lateral decubitus position with the operated side facing down; while the patients in the hypobaric groups kept lateral decubitus position facing the operated side up. During the set time intervals we evaluated how rapid was the beginning and the regression of the unilateral block; the extension of the motor and the sensoric block, the haemodinamic changes and the home admition time. Results: All of the patients included in the study tolerated the procedure well. The median time for achieving the unilateral surgical anesthesia was the shortest in hyperbaric ropivacaine group (6.95 minutes). Themaximal degree of themotor block (Bromage 3)was the highest in the hyperbaric bupivacaine group. Themedian recovery time to be able to walk and to the first urine pass was faster achieved in the hyperbaric and hypobaric ropivacaine groups (160 minutes vs.190 minutes), comparing to the hyperbaric and hypobaric bupivacaine groups (230 minutes vs.250 minutes). Side–effects were minor and infrequent in all groups. Conclusions: According to this study the baricity of the anesthetic solution has no influence in achieving successful unilateral spinal block. Ropivacain will be chosen if we want to realize a faster readiness to surgery, and a faster recovery with few side-effects and complications; all particularly appreciable in an outpatient surgery

Effects of general anaesthesia versus spinal anaesthesia for caesarean section on postoperative analgesic consumption and postoperative pain

Background and Purpose: Regional anaesthesia is commonly used for elective caesarean section.The aim of this study was to investigate whether there is a positive effect of either general or spinal anesthesia on postoperative analgesic requirements and pain relief. Methods: The level of postoperative analgesia has been compared in 64 women (ASA I or II) scheduled for elective caesarean section. General anaesthesia was performed with propofol, suxamethonium chloride,oxygen, nitrus oxide, and maintenance with 0,5% isoflurane and fentanyl. To achieve a sensory block height to the level of the sixth thoracic dermatome, spinal anaesthesia was performed with hyperbaric 0,5% levobupivacaine and 25 μg fentanyl. For all the patients postoperative analgesia was available on request without any limitation on time by administering the same dose of 75 mg i.m. diclofenac. If the patient had inadequate analgesia it was supplemented with 100 mg s.c. tramadol. Postoperative pain was recorded using visual analogue pain score as well as analgesic requirements over the first 24h after surgery. Results: The time to first request for analgesia was significantly longer in the spinal anesthesia group (p<0.05). At almost all postoperative time points,visual analogue scale scores at rest and during mobilization were lower with spinal anaesthesia (p<0.05). More patients with general anesthesia received supplemental analgesic medication. Conclusion: In parturients undergoing elective caesarean section,spinal anesthesia should be preferred because it is accompanied with less postoperative pain, less use of additional analgesics and less side effects

Novi koncept fuzijskih tehnika u regionalnoj anesteziji

The aim of this review article is to introduce a newer approach to multimodal anesthesia. In addition to the usual combination of epidural catheter and general anesthesia as standard techniques in surgical procedures accompanied by intense postoperative pain, we want to encourage reflection on the application of various regional techniques in equally complex surgical conditions. By simply modifying the standard neuraxial technique with a higher thoracic approach, excellent abdominal surgery can be performed to awake the patient. However, placement of an epidural catheter is not always possible due to technical difficulties or patient-related conditions that contraindicate its insertion. Trunk-level fascia blocks (PVB, ESPB, RLB) are simple, safe alternative to an epidural catheter because the transverse process, which is the target of ultrasound, is easily visualized and the injection site is away from neuroaxis, pleura, and large vascular structures. In addition, extensive craniocaudal diffusion of anesthetics allows wide coverage with a single injection. It has been confirmed that PVB, ESPB, RLB blocks act on visceral and somatic pain. Therefore, their ultrasound-guided use in laparoscopic and other abdominal surgeries may be useful. With a well-designed fusion of regional techniques in operations of the upper and lower abdomen, it is possible to achieve hemodynamically and respiratory stable anesthesia in an awake patient with reduced postoperative pain.Cilj ovog preglednog članka je uvesti noviji pristup multimodalnoj anesteziji. Osim uobičajene kombinacije epiduralnog katetera i opće anestezije kao standardnih tehnika u kirurškim zahvatima koji su popraćeni intenzivnom postoperativnom boli, želimo potaknuti promišljanje o primjeni različitih regionalnih tehnika u jednako složenim kirurškim stanjima. Jednostavnom modifikacijom standardne neuraksijalne tehnike s višim torakalnim pristupom, može se realizirati izvrsna abdominalna kirurgija kod budnog pacijenta. Međutim, postavljanje epiduralnog katetera nije uvijek moguće zbog tehničkih poteškoća ili stanja povezanih s pacijentom koja kontraindiciraju njegovo postavljanje. Blokovi fascije (PVB, ESPB, RLB) na razini trupa su jednostavnija i sigurnija alternativa epiduralnom kateteru jer se poprečni nastavak, koji je ciljno mjesto ultrazvuka, lako vizualizira, a mjesto ubrizgavanja udaljeno je od neuralnih struktura, pleure i velikih vaskularnih struktura. Osim toga, opsežna kraniokaudalna disperzija anestetika omogućuje široku pokrivenost jednom injekcijom. Potvrđeno je da PVB, ESPB i RLB blokovi djeluju na visceralnu i na somatsku bol; stoga njihova uporaba u laparoskopskim i drugim abdominalnim operacijama može biti korisna. Razvoj ultrazvučne tehnike omogućio je sigurniju i raznovrsniju primjenu blokova trupa u širem rasponu perioperativne analgezije. Dobro osmišljenom fuzijom regionalnih tehnika u operacijama gornjeg i donjeg abdomena moguće je ostvariti hemodinamski i respiratorno stabilnu anesteziju kod budnog bolesnika sa smanjenom razinom postoperativne boli

EPIDURALNA ADHEZIOLIZA U LIJEČENJU KRONIČNE KRALJEŽNIČKE BOLI KOD SINDROMA NEUSPJELE OPERACIJE KRALJEŽNICE I KOD LUMBALNE RADIKULARNE BOLI: JEDNOGODIŠNJE ISKUSTVO U OPĆOJ BOLNICI PULA

Aim. The aim was to evaluate the effi cacy and feasibility of percutaneous adhesiolysis to reduce pain, improve daily functions and reduce drug use in patients with chronic pain. Chronic radicular pain can be caused by scar tissue, compression, infl ammation, or swelling disks. Adhesiolysis by placement of a wire-bound catheter into the ventrolateral aspect of the epidural space at the site of the exiting nerve root enables precise application of steroids, hyaluronidase, local anesthetics and saline for to achieve pain relief. Methods: Standard percutaneous epidural adhesiolysis was performed in 54 patients divided into two groups: pain from failed back surgery syndrome (FBSS) versus chronic radicular pain without previous spine surgery. Visual analog scale (VAS) score, change in pharmacotherapy used, subjective satisfaction and evaluation of the lysis procedure were observed in pretreatment, and then in the 4th and 12th week of the intervention. Results: VAS scores for pain were signifi cantly reduced in both groups in the 4th and 12th week. A statistically signifi cant decrease was expressed in the radiculopathy group (VAS0=7.5±0.87/VAS12th=4.6±1.05) versus FBSS group (VAS0=7.6±0.85/VAS12th=5.0±1.58) (p50% was achieved in 27% of FBSS patients and 25% of patients with chronic radicular pain without surgery experience. Conclusion: Considering the small sample size, our results in short-term pain relief suggested that epidurolysis could be an effective method in the treatment of patients with chronic radicular pain as in patients with FBSS.Cilj: Cilj ove randomizirane studije bila je procjena izvodivosti i učinkovitosti adheziolize u liječenju kronične kralježničke boli, njezin utjecaj na poboljšanje kvalitete života, odnosno njezin učinak na kroničnu analgetsku terapiju. Epiduralna adhezioliza omogućava postavljanje posebno dizajniranih katetera u ventrolateralni aspekt epiduralnog prostora, tj. u neposrednoj blizini izlazaćeg živčanog korijena i preciznu primjenu steroida, hijaluronidaze i lokalnih anestetika u cilju smanjenja fenomena boli. Metoda: U studiju su usključena 54 bolesnika podijeljena u dvije skupine: bolesnici s kroničnom boli nakon neuspjele kralježničke operacije (FBSS) naspram bolesnika s kroničnom radikularnom boli bez prethodnog kirurškog iskustva. Nakon 4. odnosno 12. tjedna od postupka praćene su promjene u vizualno analognoj ljestvici boli (VAS), u farmakoterapijiskom unosu, u stupnju subjektivnog životnog zadovoljstva bolesnika, kao i procjena ukupnog učinka adheziolize. Rezultati: Prosječna razina boli (VAS) bila je značajno smanjena u obje skupine i u 4. i u 12. tjednu. Statistički značajno smanjenje izraženo je u skupini radikulopatije (VAS 0 = 7,5 0,87 / VAS 12th = 4,6 1,05) u odnosu na FBSS skupinu (VAS 0 = 7,6 0,85 / VAS 12th = 5,0 1,58) (p 50 % smanjenja inicijalne boli iskazala se u 27 % pacijenata s FBSS i u 25 % bolesnika s kroničnom radikularnom boli. Zaključak: S obzirom na naš mali uzorak, ostvareni rezultati u kratkoročnom ublažavanju boli ukazuju da epiduralna adhezioliza može biti učinkovita metoda u liječenju bolesnika s kroničnom radikularnom boli kao što je to u bolesnika s FBSS

An different approach to CSE-EVE for reducing hypothension during Caesarean section under spinal anaesthesia

Background and Objectives: Spinal anaesthesia is the most preferred anaesthetic technique for elective as well as for unplanned Caesarean section.Spinal-induced hypotension remains the most important side effect with a reported incidence between 20% and 100%. It can cause maternal discomfort (nausea and vomiting) and impaired utero-placental perfusion. The present study was designed to examine the influence of epidural volume effect on the spread and duration of low dose hyperbaric levobupivacaine. The aim of this study was to evaluate the influence of epidural restriction (injection of saline) on the distribution of anaesthesia as well as the incidence of hypotension during the spinal anaesthesia. Methods: After the approval by Ethics Committee, 60 full term parturient women (ASA I or II) with uncomplicated pregnancies were prospectively randomized into two groups: SA group (single shot spinal anaesthesia) included 37 patients and CSE-EVR (combined spinal-epidural anaesthesia) included 39 patients were we induced the restriction of the spinal space by epidural volume compression. The blocks were performed at L2/3 or L3/4 level in sitting position, in CSE-EVR group using the needle through-needle technique. The initial dose for CSE-EVR was exactly half of the SA dose (0,5 mg per 10 cm height of hyperbaric levobupivacaine and 20microg fentanyl). After spinal injection, an epidural catheter was located in the CSE-EVR and injected a volume of 20 ml saline solution. After injection women, were turned supine with a left uterine displacement. Surgery was allowed when a sensory block at or above T8 dermatome was established.We evaluated the height of the block by the pinprick method and the motor block by Bromage scale, 10 minutes after spinal injection, during the operation time and at the end of surgery. Hemodynamic monitoring (NIBP, HR) was assessed every 2 minutes until the childbirth, then every 5 minutes during operative time. Anaesthetic efficacy was evaluated for breakthrough pain by visual analogue pain score (VAPS), Apgar score at birth, umbilical artery-pH, and epinephrine consumption. Results: The level of anaesthesia 10 minutes after the induction was significantly higher in spinal group (SA) than in CSE-EVR T5 (T4-T7) vs.T7(T6-T8).The SA group experienced complete motor block during the time of anaesthesia, while the CSE-EVR group demonstrated significantly faster motor recovery. The incidence of hypotension and ephedrine supplementation was significantly lower in the CSE-EVR group (19 patients vs.35) than in the SA group (p<0.05).The neonatal outcome and umbilical artery-pH was higher in the CSE-EVR group. Both groups were comparable in demographic data, VAS scores, preloading and infusion volume, atropine or ephedrine use, and adverse effects as nausea or skin pruritus. Conclusions: We demonstrated a possible restriction of the spread of spinal anaesthesia by using epidural volume restriction with 20 ml saline as part of a combined spinal epidural technique. The study shows that CSE with EVR with only 50% of the levobupivacaine dose provided adequate anaesthesia for elective caesarean delivery, as well as better maternal hemodynamic stability

EPIDURALNA ADHEZIOLIZA U LIJEČENJU KRONIČNE KRALJEŽNIČKE BOLI KOD SINDROMA NEUSPJELE OPERACIJE KRALJEŽNICE I KOD LUMBALNE RADIKULARNE BOLI: JEDNOGODIŠNJE ISKUSTVO U OPĆOJ BOLNICI PULA

Aim. The aim was to evaluate the effi cacy and feasibility of percutaneous adhesiolysis to reduce pain, improve daily functions and reduce drug use in patients with chronic pain. Chronic radicular pain can be caused by scar tissue, compression, infl ammation, or swelling disks. Adhesiolysis by placement of a wire-bound catheter into the ventrolateral aspect of the epidural space at the site of the exiting nerve root enables precise application of steroids, hyaluronidase, local anesthetics and saline for to achieve pain relief. Methods: Standard percutaneous epidural adhesiolysis was performed in 54 patients divided into two groups: pain from failed back surgery syndrome (FBSS) versus chronic radicular pain without previous spine surgery. Visual analog scale (VAS) score, change in pharmacotherapy used, subjective satisfaction and evaluation of the lysis procedure were observed in pretreatment, and then in the 4th and 12th week of the intervention. Results: VAS scores for pain were signifi cantly reduced in both groups in the 4th and 12th week. A statistically signifi cant decrease was expressed in the radiculopathy group (VAS0=7.5±0.87/VAS12th=4.6±1.05) versus FBSS group (VAS0=7.6±0.85/VAS12th=5.0±1.58) (p50% was achieved in 27% of FBSS patients and 25% of patients with chronic radicular pain without surgery experience. Conclusion: Considering the small sample size, our results in short-term pain relief suggested that epidurolysis could be an effective method in the treatment of patients with chronic radicular pain as in patients with FBSS.Cilj: Cilj ove randomizirane studije bila je procjena izvodivosti i učinkovitosti adheziolize u liječenju kronične kralježničke boli, njezin utjecaj na poboljšanje kvalitete života, odnosno njezin učinak na kroničnu analgetsku terapiju. Epiduralna adhezioliza omogućava postavljanje posebno dizajniranih katetera u ventrolateralni aspekt epiduralnog prostora, tj. u neposrednoj blizini izlazaćeg živčanog korijena i preciznu primjenu steroida, hijaluronidaze i lokalnih anestetika u cilju smanjenja fenomena boli. Metoda: U studiju su usključena 54 bolesnika podijeljena u dvije skupine: bolesnici s kroničnom boli nakon neuspjele kralježničke operacije (FBSS) naspram bolesnika s kroničnom radikularnom boli bez prethodnog kirurškog iskustva. Nakon 4. odnosno 12. tjedna od postupka praćene su promjene u vizualno analognoj ljestvici boli (VAS), u farmakoterapijiskom unosu, u stupnju subjektivnog životnog zadovoljstva bolesnika, kao i procjena ukupnog učinka adheziolize. Rezultati: Prosječna razina boli (VAS) bila je značajno smanjena u obje skupine i u 4. i u 12. tjednu. Statistički značajno smanjenje izraženo je u skupini radikulopatije (VAS 0 = 7,5 0,87 / VAS 12th = 4,6 1,05) u odnosu na FBSS skupinu (VAS 0 = 7,6 0,85 / VAS 12th = 5,0 1,58) (p 50 % smanjenja inicijalne boli iskazala se u 27 % pacijenata s FBSS i u 25 % bolesnika s kroničnom radikularnom boli. Zaključak: S obzirom na naš mali uzorak, ostvareni rezultati u kratkoročnom ublažavanju boli ukazuju da epiduralna adhezioliza može biti učinkovita metoda u liječenju bolesnika s kroničnom radikularnom boli kao što je to u bolesnika s FBSS

SINDROM USTEZANJA OD OPIJATA U NOVOROĐENAČKOJ DOBI – ISKUSTVA DJELATNOSTI ZA PEDIJATRIJU OPĆE BOLNICE PULA (2001-2010)

Opiate abuse during pregnancy is a serious problem for both the mother and her newborn. The pregnancies of opiate abusing mothers are by definition high risk; the prenatal care is usually inadequate, abuse of alcohol, nicotine and other drugs is often present and there is a high incidence of hepatitis and HIV infections. Shortly after birth, neonates develop acute withdrawal symptoms. In Istria, in the period of 1996 to 2009 there were 2073 registered drug abusers, 355 of them were females. In our study, we present 29 newborns of opiate addicted mothers. The neonates were mostly born on term with spontaneous labor, were eutrophic and with normal Apgar scores. The withdrawal symptoms developed mainly (93%) in the first 48 hours; the most common symptoms were hyperphagia (100%), hyperirritability (79%), tremor (55%) and high-pitched cry (52%). All newborns were treated with Phenobarbital. The initial dose was 5-10 mg/kg/day in 3 to 4 divided doses and the maximal dose was 15 mg/kg/day. The duration of Phenobarbital therapy was 16,6±8,7 days and the hospital stay was 21,6±12,2 days respectively. The cost of the treatment was 13158,8±5563,3 kn. Two neonates were transported to the Pediatric Tertiary Care Center (Clinical Hospital Center Rijeka); one because of convulsions that couldn’t be managed with diazepam and Phenobarbital, and one because of apnoea after birth necessitating mechanical ventilation in an Intensive Care Unit. One newborn was referred to the Orthopedics’ ward because of major anomalies of extremities

SINDROM USTEZANJA OD OPIJATA U NOVOROĐENAČKOJ DOBI – ISKUSTVA DJELATNOSTI ZA PEDIJATRIJU OPĆE BOLNICE PULA (2001-2010)

Opiate abuse during pregnancy is a serious problem for both the mother and her newborn. The pregnancies of opiate abusing mothers are by definition high risk; the prenatal care is usually inadequate, abuse of alcohol, nicotine and other drugs is often present and there is a high incidence of hepatitis and HIV infections. Shortly after birth, neonates develop acute withdrawal symptoms. In Istria, in the period of 1996 to 2009 there were 2073 registered drug abusers, 355 of them were females. In our study, we present 29 newborns of opiate addicted mothers. The neonates were mostly born on term with spontaneous labor, were eutrophic and with normal Apgar scores. The withdrawal symptoms developed mainly (93%) in the first 48 hours; the most common symptoms were hyperphagia (100%), hyperirritability (79%), tremor (55%) and high-pitched cry (52%). All newborns were treated with Phenobarbital. The initial dose was 5-10 mg/kg/day in 3 to 4 divided doses and the maximal dose was 15 mg/kg/day. The duration of Phenobarbital therapy was 16,6±8,7 days and the hospital stay was 21,6±12,2 days respectively. The cost of the treatment was 13158,8±5563,3 kn. Two neonates were transported to the Pediatric Tertiary Care Center (Clinical Hospital Center Rijeka); one because of convulsions that couldn’t be managed with diazepam and Phenobarbital, and one because of apnoea after birth necessitating mechanical ventilation in an Intensive Care Unit. One newborn was referred to the Orthopedics’ ward because of major anomalies of extremities