Breakthrough pain - management and treatment

Probijajuća bol (PB) kod karcinoma definira se kao tranzitorna egzacerbacija boli kod bolesnika sa stabilnom i kontroliranom osnovnom boli. PB i osnovna bol odvojene su komponente karcinomske boli i zahtijevaju odvojen terapijski pristup. Liječenje PB-a uključuje interdisciplinarni i multimodalni pristup. Uobičajeno liječenje PB-a provodi se dodatnim dozama opioida, poznatim kao spasonosna medikacija.Breakthrough cancer pain is defined as transient pain exacerbation in patients with stable and controlled basal pain. Persistent and breakthrough pain are distinct components of cancer pain and require separate management. The management of breakthrough cancer pain should involve an interdisciplinary and multimodal approach. A specific assessment and precise pain characterization are essential to plan the most appropriate treatments. The usual approach to managing breakthrough pain is with supplemental doses of opioids, also known as rescue medication

Reducing the incidence of adverse events in anesthesia practice

Background and purpose: adverse event during anesthesia is defined as an event that may result in the development of complications and is caused by human error, failure of the apparatus, the selected anesthetic techniques and individual reaction of the patient. Timely detection of adverse events prevents complications and their analysis through the register of the same to the adoption of preventive and remedial measures. Materials and methods:The Department of Anesthesiology in General Hospital Karlovac, in accordance with the accreditation standards of the Republic of Croatia monitors adverse events during anesthesia, the waking up period and the stay on the ward during the first 24 hours, and the type of anesthesia techniques applied. Results: During the 2012, a total of 4244 anesthesia with a 1.25% complications was done.We have been monitoring the number of anesthesia since 2011. when the percentage of complications was 5.4%. This is the basis to conclude that there is a tendency to reduce the number of complications. Anesthesia was classified as general and regional. The use of ultrasound contributes to safety of regional anesthesia, especially nerve conduction anesthesia of extremities and thus reducing the volume of local anesthetic administered and its toxicity. The incidence of complications of regional anesthesia among all regional anesthesias done during the 2012 was 0,31%. Conclusion: Keeping the register of complications during anesthesia has led to increased awareness of the need to record them and analyze the causes and consequences of complications at the department meetings. There is a trend of increased use of regional anesthesia techniques as indicated

PAIN AND ITS PREVENTION IN CHRONIC WOUND

U ovom preglednom članku opisan je patomehanizam nastanka bolnog osjeta i put njegovog širenja od mjesta ozljede do korteksa s posebnim osvrtom na pojavu boli kod kronične rane i važnosti njenog pravodobnog i pravovaljanog liječenja Istaknuto je značenje nociceptora (prihvatača bolnih podražaja) i kemijskih posrednika (neurotransmitera) te alogenih tvari koje se oslobađaju na mjestu ozljede i podražuju nocicepcijske neurone. U liječenju je naglašena primjena farmakoterapije (analgetici). Kao temelj racionalne primjene analgetika preporuča se »trostupanjska» ljestvica SZo. Istaknuta je potreba kombinacije farmakoterapije s nefarmakološkim postupcima (kirurški, izikalni). Posebno je istaknut pozitivni učinak VIP svjetla na ubrzanje zacjeljenja kronične rane.This article describes the pathomechanism of the development of painful sensation and its spread from the site of injury to the cortex, with special reference to pain in chronic injury, as well as the importance of timely and proper treatment. Special attention is paid to nociceptors (recipients of painful stimuli) and chemical intermediaries (neurotransmitters), as well as to allogeneic substances released at the site of injury to stimulate nociceptive neurons. Treatment is focused on pharmacotherapy (analgesics). The recommended basis for the rational use of analgesics is the Who "three-degree” scale. The need of combining pharmacotherapy with non-pharmacological elements (surgical, physical) is also stressed. The positive effect of VIP light on faster healing of chronic injuries is especially highlighted

MALIGNANT PAIN IN EMERGENCY MEDICINE

Bol je potrebno liječiti prema prihvaćenim smjernicama, a cilj je našeg istraživanja bio utvrđivanje učestalosti i osobitosti intervencija u izvanbolničkoj hitnoj medicini (HMP) zbog liječenja maligne boli. Učinili smo retrospektivnu analizu prospektivne baze podataka Nastavnog zavoda za hitnu medicinu Grada Zagreba u razdoblju od 1. siječnja do 31. prosinca 2014.godine. U ispitivanje su uključeni bolesnici oboljeli od maligne bolesti, a razlog intervencija tima hitne medicinske pomoći bila je maligna bol. Analizirani su: demografski podatci (dob, spol), struktura ispitanika prema vrsti maligne bolesti (Međunarodna klasifikacija bolesti), vrijeme intervencije (noć/dan), vrijeme intervencije prema danu u tjednu, vrsta primijenjenog analgetika (neopioid, opioid, adjuvantni analgetik) i načinu unosa analgetika u organizam. Podatci su prikazani u tablicama, kategorijske i nominalne vrijednosti prikazane su odgovarajućim frekvencijama i udjelima. U promatranom razdoblju HMP Zagreb imao je 70 155 intervencija, a zbog maligne boli ih je bilo 516 (0,74 %): 265 (51 %) bolesnica 251 (49 %) bolesnika. Povećan udio starije dobne skupine uzrok je sve većeg broja novootkrivenih bolesnika s malignim bolestima. Tako distribucija bolesnika prema dobnim skupinama pokazuje da je najveći broj bolesnika bio između 60. i 80. godine života (335 ili 64,91 %). Između 50. i 60. godine života pomoć je zatražio dvostruko manji broj bolesnika - 85 (16,47 %). Prema MBK klasifi kaciji bolesti najčešći uzrok bolova zbog kojih su bolesnici zatražili pomoć HMP-a bile su zloćudne novotvorine probavnih organa (138, 26,74%), respiratornih i intratorakalnih organa (10,5, 20,34 %). Tijekom dana ekipa HMP-a obavila je 288 (55,81 %) intervencija, tijekom noći 228 (44,19 %) .Tijekom vikenda obavljeno je 178 (34,36 %) intervencija, a radnim danom 340 (65,64 %). Ove intervencije posljedica su specifične organizacije rada izvanbolničkih zdravstvenih djelatnosti. Neopioidni su analgetici kao prva stepenica u liječenju maligne boli primijenjeni su puta 303 (58,72 %), slabi opioidi 205 puta (39,74 %), a jaki opioidi 8 puta (1,55 %). Glavna prepreka za optimalno liječenje boli je neadekvatna procjena boli. Najčešća je bila intramuskularna primjena analgetika (483, 93,24 %), a potom intravenska (21, 4,05 %) i supkutana (10, 1,93 %). Zaključujemo da je neophodno potrebno educirati timove HMP-a s naglaskom na procjenu jačine boli ljestvicama za bol uz propisivanje analgetske terapije sukladno preporukama.It is necessary to treat pain according to accepted guidelines and the goal of our research was to determine the frequency and characteristics of interventions in outpatient emergency medical services (EMS) for the treatment of malignant pain. We performed retrospective analysis of the prospective database of the Zagreb Municipal Teaching Institute of Emergency Medicine in the period from January 1 to December 31, 2014. The study included patients suffering from malignant diseases and malignant pain as the reason for the EMS team intervention. We analyzed demographic data (age, gender), structure of patients by type of malignant disease (International Classifi cation of Diseases, ICD), time of intervention (night/day), time of intervention according to day of the week, type of analgesics applied (non-opioid, opioid analgesic or adjuvant), and the route of painkiller administration. Data are presented in tables, categorical and nominal values are shown as appropriate frequencies and shares. Zagreb EMS had 70,155 interventions in the period observed, of which 516 (0.74%) patients with malignant pain, including 265 (51%) female and 251 (49%) male patients. The increased proportion of elderly population caused a growing number of newly diagnosed patients with malignant diseases. Therefore, distribution of patients according to age groups showed that the highest number of patients were in the 60-80 age group (n=335; 64.91%). Eighty-five (16.47%) patients aged 50-60 requested help from EMS. According to the ICD, the most common cause of pain for which patients sought help from EMS were malignant neoplasms of digestive organs (n=138; 26.4%), respiratory and intrathoracic organs (10.5% and 20.34%, respectively). The EMS team had 288 (55.81%) interventions during the day and 228 (44.19%) interventions during the night. They had 178 (34.36%) interventions over weekend and 340 (65.64%) interventions on work days. These interventions are the result of the specifi c work organization of outpatient hospital health services. Non-opioid analgesics as the fi rst step in the treatment of malignant pain were administered 303 (58.72%) times, weak opioids 205 (39.74) times, and strong opioids 8 (1.55%) times. The main obstacle to optimal pain management is inadequate assessment of pain. Intramuscular administration of analgesics (n=483; 93.24%) was most frequent, followed by intravenous (n=21; 4.05%) and subcutaneous (n=10; 1.93%) route. We conclude that it is necessary to educate EMS teams, especially focusing on the assessment of the degree of pain using scales for pain with prescription of analgesic therapy in accordance with recommendations

Nutritional support in Intensive Care Units Time for personalization?

Klinička prehrana je važan dio intenzivne skrbi. Nutritivni status ima prognostičku vrijednost u kritično oboljelih pacijenata. Prehrana u jedinici intenzivne medicine je složena terapija koja zahtijeva interdisciplinarni pristup i česte ponovne provjere. Optimalnu nutritivnu terapiju potrebno je primjenjivati tijekom kritične bolesti, nakon otpusta s odjela intenzivne medicine te nakon otpusta iz bolnice. Nutritivne potrebe se mijenjaju ovisno o fazi kritične bolesti te je stoga uvijek potrebno upotrijebiti individualni pristup pacijentu. Pacijenti u jedinicama intenzivne medicine su heterogena skupina i generalizirane preporuke se ne mogu primijeniti na svakog pacijenta. Personaliziranu nutritivnu terapiju je potrebno propisati i pratiti. Upotreba definirane strategije praćenja je sljedeći korak prema individualizaciji nutritivne terapije.Clinical nutrition is an important part of critical care. Nutritional status has prognostic impact in the critically ill. Nutrition in the ICU is a complex therapy requiring an interdisciplinary approach and frequent reevaluation. Optimal nutrition therapy should be provided during critical illness, after intensive care unit (ICU) discharge, and following hospital discharge. Nutritional requirements will vary according to the phase of critical illness and an individualized approach should always be used. ICU patients are a heterogeneous group and generalized recommendation for every patient cannot be sugested. Personalized nutrition therapy should be prescribed and monitored. The use of a defined monitoring strategy is the next step to individualisation of nutritional therapy

PAIN AND GUIDELINES FOR PAIN PREVENTION IN CHRONIC WOUND

U ovom preglednom članku opisan je patomehanizam nastanka bolnog osjeta sa posebnim osvrtom na pojavu boli kod kronične rane. Prikazane su smjernice (preporuke) za njeno liječenje. U liječenju je stavljen naglasak na farmakoterapiju (analgetici). Kao temelj racionalne primjene analgetika preporuča se »trostupanjska» ljestvica SZO-e. Istaknuta je potreba kombinacije farmakoterapije s nefarmakološkim postupcima (kirurški, fi zikalni). Posebno je istaknut pozitivni učinak VIP svjetla na ubrzanje zacjeljenja kronične rane.This review article describes the occurrence of painful sensation with special reference to the occurrence of pain in chronic wounds, and presents recommendations for medical treatment of pain. Treatment is focused on pharmacotherapy. The recommended basis for rational use of analgesics is the WHO ‘three-degree’ scale. The need for combining pharmacotherapy with non-pharmacological treatment is also stressed. The positive effect of Visible Incoherent Polarized (VIP) light on the acceleration of chronic wound healing is highlighted

ISTRAŽIVANJE UTJECAJA PANDEMIJE COVID-19 NA LIJEČENJE KRONIČNE BOLI U HRVATSKOJ

The purpose of this study was to examine the impact of the COVID-19 pandemic on outpatient treatment of pain in general and specialized hospitals and clinics in Croatia. A survey was conducted among pain medicine specialists and members of the Croatian Association for the Treatment of Pain (CATP). The survey was designed using Google Forms and it consisted of 17 questions divided into fi ve sets. CATP members completed the survey anonymously and their answers were analyzed. The survey was open for one month (January to February 2021). A total of 41 members completed the survey. The results have shown that 90.2% of the respondents agree that the COVID-19 pandemic has changed chronic pain treatment. An increase in pain intensity was reported by 58.5% of patients. A decrease in the use of opioids (45%) and adjuvant analgesics (35%) was detected. The majority of the respondents reported a decline in the use of interventional pain management procedures (92%). CATP members switched to electronic and telemedicine technologies to communicate with their patients, considering them a good alternative during the pandemic. A lack of national guidelines on chronic pain treatment during the pandemic was reported by 78% of the respondents. The study concluded that the COVID-19 pandemic has decreased the number of outpatient chronic pain examinations considerably. The pandemic has affected therapeutic procedures, reduced personal contact between physicians and patients, and decreased the overall quality of treatment.Svrha ovog rada bila je istražiti učinak pandemije COVID-19 na liječenje kronične boli u ambulantama za liječenje boli općih i specijalnih bolnica te kliničkih ustanova u Hrvatskoj. Provedena je anketa među specijalistima za bol i članovima Hrvatskoga društva za liječenje boli (HDLB). Anketni upitnik je izrađen uz pomoć Google servisa Google forms, a sastoji se od 17 pitanja grupiranih u pet skupina. Članovi HDLB su anonimno ispunili upitnik te su se njihovi odgovori kasnije analizirali. Anketu je bilo moguće ispuniti u razdoblju od mjesec dana (siječanj-veljača 2021.). Na anketu je odgovorio ukupno 41 član. Rezultati su pokazali kako se 90,2 % ispitanika slaže da je pandemija COVID-19 promijenila način liječenja kronične boli. Veći intenzitet boli prijavilo je 58,5 % bolesnika. Otkriveno je smanjenje uporabe opioida (45 %) i adjuvantnih analgetika (35 %). Većina ispitanika je prijavila smanjenje interventnih postupaka za liječenje boli (92 %). Članovi HDLB su koristili elektroničke i telemedicinske načine komunikacije s pacijentima kao dobru alternativu u uvjetima pandemije. Nedostatak nacionalnih smjernica za liječenje kronične boli u uvjetima pandemije prijavilo je 78 % članova društva. Ovom studijom smo zaključili da je pandemija COVID-19 značajno smanjila broj ambulantnih pregleda pacijenata s kroničnom boli. Pandemija je imala utjecaj na terapijske postupke, smanjila osobni kontakt liječnika s pacijentom te ukupno smanjila kvalitetu liječenja