Acute pain

Posljednjih desetak godina snažna nocicepcijska somatska i visceralna akutna bol smatra se najvažnijim čimbenikom razvoja endokrinih i neurohumoralnih poremećaja u neposrednome postoperacijskom ili posttraumatskom razdoblju te u nizu ostalih kliničkih stanja praćenih snažnom akutnom boli. Poznavanje i razumijevanje neurofiziologije akutne boli te brzih mehanizama koji dovode do pojave kroničnoga bolnog sindroma nalaže primjenu agresivnih modaliteta liječenja akutne boli. Akutna je bol normalan, predvidljiv fiziološki odgovor na štetni podražaj, izazvan akutnom bolesti, koji narušava zdravlje i ugrožava tjelesni integritet te stoga ima upozoravajući zaštitni učinak. Cilj je liječenja potpuno uklanjanje akutne boli multimodalnim pristupom te primjenom koncepta preventivne analgezije. U članku su iznesene ključne preporuke za primjenu neopioidnih, opioidnih i adjuvantnih lijekova u liječenju akutne boli. Istaknute su prednosti regionalnih tehnika liječenja te je kratko prikazano liječenje akutne boli u određenim kliničkim stanjima.Over the last decade, a strong nociceptive somatic and visceral acute pain has been considered as the most important factor in the development of endocrine and metabolic disorders in postoperative and posttraumatic periods or in other painful clinical situations. A better knowledge and understanding of the acute pain neurophysiology and fast pathogenic mechanisms which lead to pain chronification require aggressive pain analgesic strategies. Acute pain is a normal, physiological response to a noxious stimulus and it has a protective function. The aim of treatment is to achieve a complete pain relief with multimodal preventive analgesic techniques. This paper provides an update on pharmacotherapy recommendations, emphasizes the advantages of regional analgesic techniques and discusses the acute pain treatment in special clinical situations

Acute pain

Posljednjih desetak godina snažna nocicepcijska somatska i visceralna akutna bol smatra se najvažnijim čimbenikom razvoja endokrinih i neurohumoralnih poremećaja u neposrednome postoperacijskom ili posttraumatskom razdoblju te u nizu ostalih kliničkih stanja praćenih snažnom akutnom boli. Poznavanje i razumijevanje neurofiziologije akutne boli te brzih mehanizama koji dovode do pojave kroničnoga bolnog sindroma nalaže primjenu agresivnih modaliteta liječenja akutne boli. Akutna je bol normalan, predvidljiv fiziološki odgovor na štetni podražaj, izazvan akutnom bolesti, koji narušava zdravlje i ugrožava tjelesni integritet te stoga ima upozoravajući zaštitni učinak. Cilj je liječenja potpuno uklanjanje akutne boli multimodalnim pristupom te primjenom koncepta preventivne analgezije. U članku su iznesene ključne preporuke za primjenu neopioidnih, opioidnih i adjuvantnih lijekova u liječenju akutne boli. Istaknute su prednosti regionalnih tehnika liječenja te je kratko prikazano liječenje akutne boli u određenim kliničkim stanjima.Over the last decade, a strong nociceptive somatic and visceral acute pain has been considered as the most important factor in the development of endocrine and metabolic disorders in postoperative and posttraumatic periods or in other painful clinical situations. A better knowledge and understanding of the acute pain neurophysiology and fast pathogenic mechanisms which lead to pain chronification require aggressive pain analgesic strategies. Acute pain is a normal, physiological response to a noxious stimulus and it has a protective function. The aim of treatment is to achieve a complete pain relief with multimodal preventive analgesic techniques. This paper provides an update on pharmacotherapy recommendations, emphasizes the advantages of regional analgesic techniques and discusses the acute pain treatment in special clinical situations

Analgesia and sedation in hemodynamic unstable patient

Pain, restlessness, tension and delirium are almost always encountered while treating hemodynamic unstable critical patients in the intensive care units. Usually in critical patients, the evaluation of the nature and pain intensity (VAS scale) are often impossible. During the last 10 years intense nociceptor somatic and visceral post operative pain is believed to be the most crucial factor in the development of endocrine and neurohumoral disorders, within the postoperative period. Chronic post operative pain is appearing often (30%-40%), with great influence on the quality of patients life. The modern principal in treating acute pain is the use of multimodal balanced analgesia approach, which is individually catered with drug and dose for each patient. Modern systemic analgesia is understood to be the continuous use of opiates or opioids, titrated towards pain intensity, with a minimum number of complications even in hemodynamic unstable patients. The combined use of opioids with NSAID and paracetamol reduces the overall dosage of opioids by 20% - 30% and therefore significantly contributes to hemodynamic and respiratory stability. Effective and safe epidural analgesia in hemodynamic unstable patients can be optimized by simultaneous use of various drugs with different mechanisms of action (local anaesthetic, opioid, adrenalin, ketamin). The accepted concept of analgosedation in critical patients is understood to be the use of short acting drugs (fentanyl, sufentanil, remifentanil, midazolam, propofol) in which drug dosage can be quickly adjusted in respect to the present clinical state of the patient

Transfusion related acute lung injury (TRALI)

Transfusion-related acute lung injury (TRALI) is a complication following transfusion of blood products and is potentially a life-threatening adverse event of transfusion. The first case of fatal pulmonary edema following transfusion was reported in the 1950s. In recent time, TRALI has developed from an almost unknown transfusion reaction to the most common cause of transfusion related major morbidities and fatalities. A clinical definition of TRALI was established in 2004, based on acute respiratory distress which has temporal association with transfusion of blood components. In 2008 a distinction between classic and delayed syndrome was proposed. However, pathophysiology of TRALI still remains controversial. A number of different models were proposed to explain the pathogenesis. The two, presently most accepted models, are not mutually exclusive. The first is the antibody mediated model and the second is the two-event model. In this review article the definition of TRALI, patient predisposition, treatment, prevention and reporting guidelines are examined. The current knowledge on the topic TRALI is summarized

Effect of postoperative pain therapy on surgical outcome

Although efficient treatment of post-surgical pain is considered to be a pre-condition for a normal course of the post-surgical period, epidemiological and clinical research show that a significant number of patients still suffer intense pain after major surgery. Intense nociceptive somatic and visceral post-surgical pain has in the last ten years been considered the most important development of endocrine and neurohumoral disorders in the immediate post-surgical period, (the vital organ functional disorders, occurence of serious ostoperative complications and prolonged hospitalisation.) The effects of successful perioperative analgesia on the course and outcome of surgical patients remains disputable, particularly because there is no consensus on the optimal procedure for specific pain therapy. The multimodal analgesia (defined as use of NSAIDs, COX–2 inhibitors or paracetamol in combination with i.v. opioid PCA ) results in an opioid sparing effect. However, this opioid reduction does not consistently result in decreased opioid side effects. The overall negative outcome effects by i.v. opioids PCA correspond well with minor effects on postoperative dynamic pain, stress response and organ dysfunctions. At present the entire role of perioperative epidural technique on patient outcome is unclear. Also, the advantages of epidural analgesia have to be balanced against their risk and cost. The concept of multi-modal analgesia is an area of most importance and where future research efforts should focus on the combination of several techniques such as continuous peripheral nerve-blocks, continuous wound-infusion of local anaesthetics, NSAIDs/COX-2 inhibitors, paracetamol, α-2 agonists, ketamine, dextromethorphane, gabapentin/pregabalin, glucocorticoids etc

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

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

The Relationship between Prolonged Cerebral Oxygen Desaturation and Postoperative Outcome in Patients Undergoing Coronary Artery Bypass Grafting

58 patients who underwent on-pump coronary artery bypass graft surgery were evaluated for changes in regional cerebral oxygen saturation (rSO2) measured by near infrared spectroscopy (NIRS). If rSO2 during the operation fell to more than 20% under the baseline, standardized interventions were undertaken to maintain rSO2. Despite those interventions, in some cases we observed inability to maintain rSO2 above this threshold. Therefore we divided patients in two subgroups: 1. without prolonged rSO2 desaturation; 2. with prolonged rSO2 desaturation (area under the curve >150 min% for rSO250 min% for rSO2<50% of absolute value). The data were analyzed to determine whether there were major differences in outcome of these two groups. 18 out of 58 patients (31%) had prolonged rSO2 desaturation during operation. There was significantly higher number of diabetic patients in group with prolonged rSO2 desaturation (p=0.02). Intraoperative data revealed significantly more blood consumption during cardiopulmonary bypass (p=0.007) and the need for inotropes (p=0.04) in desaturation group. Three patients in prolonged desaturation group and no one in another group had stroke, coma or stupor (p=0.03). Logistic regression analysis revealed diabetes mellitus and age as predictors for prolonged rSO2 desaturation. We concluded that prolonged intraoperative rSO2 desaturation is significantly associated with worse neurological outcome in patients – nonresponders to standardized interventions for prevention of rSO2 desaturation