Surgery causes postoperative pain that should be immediately and effectively treated. Postoperative pain management is in central focus when planning postoperative treatment and is becoming the ...standard of care after surgical protocols – Enhanced Recovery after Surgery (ERAS). There are various serious complications associated with poorly controlled postoperative pain in adult surgical patients – cardiopulmonary complications, unplanned hospital admission, prolonged hospital stays, development of chronic pain, opioid side effects, opioid hyperalgesia and addiction. Studies have identified activation and sensitization of peripheral nociceptors and spinal dorsal horn neurons after surgical incision, and their specific mechanisms have been investigated. Basic scientific data and many clinical investigations suggest that different pain states result depending on the type and location of the incision, and that additional surgical procedures cause pain states of various severities in other sites. Supported by basic science, these observations have led to the development of the concept of procedure-specific postoperative pain management. The main value and novelty of procedure-specific postoperative pain management guidelines are that the guidelines are evidence-based, consider relevant patient characteristics, the role of anesthetic and surgical techniques, the balance between the invasiveness of the analgesic technique and the intensity of postoperative pain, as well as balance between analgesic efficacy and adverse event profile of the analgesic medications and procedures. In this review, the authors discuss the preventive and multimodal strategies of acute pain therapy, the pharmacotherapy of multimodal analgesia and local and regional techniques for specific surgical procedures.
The most common causes of lumbar radicular pain are pathological changes in the intervertebral disc. Lumbar disc herniation (LDH) is the most common cause of lumbosacral radicular syndrome. It ...affects 1-2% of the general population, burdening health services and the economy worldwide. Excessive scar tissue after lumbar microdiscectomy can increase postoperative pain. Postoperative fibrosis is one of the most important causes of failed back surgery syndrome after lumbar disc surgery. Percutaneous laser disc decompression (PLDD) is a minimally invasive procedure in which thermal energy produced by a LASER probe is used to reduce the intervertebral disc herniation located within the annulus fibrosus. Evaporation of a small volume in a closed hydraulic space (nucleus pulposus) leads to decreased intradiscal pressure. It causes a thermal “shrinkage effect” with the retreat of the herniated disc and the decompression of the nerve root, which reduces lumbar radicular pain. Previous research has shown effective reduction of pain after PLDD and only a small number of complications of the procedure itself. PLDD is a safe and effective procedure in well-selected patients. Unfortunately, there is still a need for extensive, randomized prospective studies on PLDD in lumbar radicular pain in order to confirm or dispute the results obtained so far.
The personalization of pain treatment in intensive care units was developed due to the interindividual variability and heterogeneity of critically ill patients. A personalized approach to pain is ...based on the prediction and continuous assessment of pain. In critically ill patients, this approach includes the knowledge of the underlying cause of pain related to the primary diagnosis, the causes of procedural pain and previous chronic pain conditions of the patient, in order to apply a specific therapeutic approach. Available treatment recommendations emphasize the use of adaptive or dynamic analgesia, with titration of analgesics according to changes in the clinical state of patients. They indicate the necessity of pain assessment with tools for pain intensity assessment and therapy evaluation, as well as the need for assessment at regular time intervals. Despite treatment guidelines, clinical practice shows significant deviations from evidence-based recommendations. The reasons are primarily the non-recognition of pain, insufficient knowledge of analgesics (type and dose), lack of regular assessment and inadequacy of the applied tools for pain assessment. In terms of personalization, there is a need to develop objective pain assessment methods, such as sensitive and pain-specific tools that do not rely on the patient’s ability to communicate and are independent of assessors, disease characteristics and pharmacological interventions in critically ill patients.
Proximal femoral fractures are a major public health problem because of the increasing proportion of elderly individuals in the general population. The mode of choice for anaesthesia in surgical ...treatment of these fractures is still debated in terms of better postoperative outcome.
The aim of our study was to compare the effect of general over spinal anaesthesia on mortality in proximal femoral fracture surgery.
This study was a retrospective analysis of 115 patients aged at least 70 years who underwent surgery for proximal femoral fracture. The survey was conducted from 1 January to 31 December 2015 at the General Hospital Karlovac, Croatia. Patients were divided into two groups: group 1 – general anaesthesia and group 2 – spinal anaesthesia.
The primary outcome measure was the effect of mode of anaesthesia, general versus spinal, on mortality within 30 days, six months and one year after surgery.
General anaesthesia (EndoTracheal Anaesthesia) was administered in 77 patients (67%; group I – ETA) and spinal anaesthesia in 38 patients (33%; group 2 – SPIN). Both groups had more female than male patients: 69 patients (89.6%) in the ETA group and 32 patients (84.2%) in the SPIN group were female.
The mean age in the ETA group was 82.91 years and in the SPIN group was 80.18 years.
ASA II status was more common in patients in the SPIN group (25 patients 65.8%).
The average time from hospitalisation to surgery was 53.44 hours in the ETA group and 53.33 hours in the SPIN group. There was no significant difference between groups in the number of comorbidities, or intraoperative and postoperative complications.
There was no statistically significant difference in mortality between the groups. Mortality after surgery in the ETA and SPIN groups, respectively, was as follows: 10.4% and 10.5% at 30 days, 23.4% and 15.8% at six months, and 32.5% and 31.6% at one year.
The results indicate that the mode of anaesthesia (general vs spinal) has no effect on postoperative mortality, and that the mode of anaesthesia should be applied on an individual basis in correlation with associated comorbidities.
The aim of the study was to show the role of tools in the evaluation of chronic pain (CP) in general practitioner (GP) everyday clinical practice. The study was done by analyzing electronic database ...of the first visits of 1090 CP patients referred to the Pain Clinic of the Karlovac General Hospital, Karlovac, Croatia, by their GPs. All patient records were analyzed according to the cause of CP, strongest pain a week before the examination, quality of sleep, and the Patients' Global Impression of Change scale. All statistical analyses were done using the IBM SPSS Statistics version 19.0.0.1 (www.spss.com). CP predominantly occurs in older age group. Patients with musculoskeletal pain accounted for the highest percentage (n = 316; 29%), followed by those with neuropathic pain (n = 253; 23.20%) and those with low back pain (n = 225; 20.60%). The mean pain intensity rating scale score was 8.3 ± 1.8 a week before the examination and the mean quality of sleep score was 6.8 ± 1.9. Moderate and severe sleep quality disorder was significantly present in patients over 65 years of age (p = 0.007), patients with musculoskeletal and neuropathic pain, back pain, and those having rated Patients' Global Impression of Change scale as worsening (p = 0.001). The severity of pain and poor quality of sleep are the leading causes of deterioration of the Patients' Global Impression of Change scale in patients suffering from musculoskeletal and neuropathic pain. In order to treat CP comprehensively, it is important for GPs to evaluate the outcomes of clinical treatment using tools for CP assessment.
Surgery causes postoperative pain that should be immediately and effectively treated. Postoperative pain management is in central focus when planning postoperative treatment and is becoming the ...standard of care after surgical protocols - Enhanced Recovery after Surgery (ERAS). There are various serious complications associated with poorly controlled postoperative pain in adult surgical patients - cardiopulmonary complications, unplanned hospital admission, prolonged hospital stays, development of chronic pain, opioid side effects, opioid hyperalgesia and addiction. Studies have identified activation and sensitization of peripheral nociceptors and spinal dorsal horn neurons after surgical incision, and their specific mechanisms have been investigated. Basic scientific data and many clinical investigations suggest that different pain states result depending on the type and location of the incision, and that additional surgical procedures cause pain states of various severities in other sites. Supported by basic science, these observations have led to the development of the concept of procedure-specific postoperative pain management. The main value and novelty of procedure-specific postoperative pain management guidelines are that the guidelines are evidence-based, consider relevant patient characteristics, the role of anesthetic and surgical techniques, the balance between the invasiveness of the analgesic technique and the intensity of postoperative pain, as well as balance between analgesic efficacy and adverse event profile of the analgesic medications and procedures. In this review, the authors discuss the preventive and multimodal strategies of acute pain therapy, the pharmacotherapy of multimodal analgesia and local and regional techniques for specific surgical procedures. Key words: postoperative pain management; procedure-specific analgesia; multimodal and preventive analgesia; evidence-based data Operacija uzrokuje postoperativnu bol koju treba odmah ucinkovito lijeciti. Lijecenje postoperativnom boli u sredisnjem je fokusu u planiranju postoperativnog lijecenja i postaje standard skrbi nakon kirurskih protokola - poboljsani oporavak nakon operacije (ERAS). Postoje razne ozbiljne komplikacije povezane s lose kontroliranom postoperativnom boli kod odraslih kirurskih pacijenata - kardiopulmonalne komplikacije, neplanirani prijem u bolnicu, produljeni boravak u bolnici, razvoj kronicne boli, opioidne nuspojave, opioidna hiperalgezija i ovisnost. Nakon kirurskog reza identificirana je aktivacija i senzibilizacija perifernih nociceptora i neurona dorzalnog roga kraljeznice te su istrazeni njihovi specificni mehanizmi. Osnovni znanstveni podaci i mnoga klinicka istrazivanja sugeriraju da ovisno o vrsti i mjestu reza dolazi do razlicitih bolnih stanja i da razliciti kirurski zahvati uzrokuju bolna stanja razlicite jacine na razlicitim mjestima. Potpomognuta osnovnom znanoscu, ova su opazanja dovela do razvoja koncepta lijecenja postoperativne boli specificnog zahvata. Glavna vrijednost i novost "Procedure-specific postoperative pain management" smjernica je da se smjernice temelje na dokazima, vode racuna o relevantnim karakteristikama bolesnika, ulozi anestezijskih i kirurskih tehnika, ravnotezi izmedu invazivnosti analgetske tehnike i intenziteta postoperativne boli, kao i ravnotezu izmedu analgetske ucinkovitosti i profila nuspojava analgetickih lijekova i tehnika. U ovom pregledu autori raspravljaju o preventivnim i multimodalnim strategijama terapije akutne boli, farmakoterapiji multimodalne analgezije te lokalnim i regionalnim tehnikama za specificne kirurske postupke. Kljucne rijeci: lijecenje postoperativne boli, analgezija specificna za postupak, multimodalna i preventivna analgezija, podaci temeljeni na dokazima
The most common causes of lumbar radicular pain are pathological changes in the intervertebral disc. Lumbar disc herniation (LDH) is the most common cause of lumbosacral radicular syndrome. It ...affects 1-2% of the general population, burdening health services and the economy worldwide. Excessive scar tissue after lumbar microdiscectomy can increase postoperative pain. Postoperative fibrosis is one of the most important causes of failed back surgery syndrome after lumbar disc surgery. Percutaneous laser disc decompression (PLDD) is a minimally invasive procedure in which thermal energy produced by a LASER probe is used to reduce the intervertebral disc herniation located within the annulus fibrosus. Evaporation of a small volume in a closed hydraulic space (nucleus pulposus) leads to decreased intradiscal pressure. It causes a thermal "shrinkage effect" with the retreat of the herniated disc and the decompression of the nerve root, which reduces lumbar radicular pain. Previous research has shown effective reduction of pain after PLDD and only a small number of complications of the procedure itself. PLDD is a safe and effective procedure in well-selected patients. Unfortunately, there is still a need for extensive, randomized prospective studies on PLDD in lumbar radicular pain in order to confirm or dispute the results obtained so far. Key words: percutaneous laser disc decompression; discectomy; lumbar radicular pain; disc protrusion Najcesci uzrok lumbalne radikularne boli su patoloske promjene intervertebralnog diska. Lumbalna diskus hernija (LDH) je najcesci uzrok lumbosakralnog radikularnog sindroma i pogada 1-2% opce populacije, stavljajuci znacajan teret na zdravstvene usluge i gospodarstvo u cijelom svijetu. Prekomjerna kolicina oziljnog tkiva nakon lumbalne mikrodiscektomije moze povecati postoperativnu bol. Postoperativna fibroza je jedan od najvaznijih uzroka sindroma neuspjele operacije leda nakon operacije lumbalnog diska. Perkutana laserska dekompresija diska (PLDD) je vrsta minimalno invazivnog zahvata u kojem se toplinska energija proizvedena LASER sondom koristi za smanjenje hernije interverterbralnog diska koja se nalazi unutar fibroznog prstena. Isparavanje malog volumena u zatvorenom hidraulickom prostoru (nucleus pulposus) dovodi do smanjenja intradiskalnog tlaka i implicira termicki"ucinak skupljanja" sa povlacenjem hernije diska i dekompresiju zivcanog korijena sto ima za posljedicu smanjenja lumbalne radikularne boli. Dosadasnja istrazivanja pokazala su ucinkovito smanjenje boli poslije PLDD, te mali broj komplikacija samog zahvata. PLDD je siguran i djelotvoran zahvat kod dobro probranih bolesnika. Nazalost, ne postoje jos velike, randomizirane prospektivne studije iz PLDD kod lumbalne radikularne boli, te su navedena istrazivanja potrebna u buducnosti kako bi potvrdila ili osporila dosadasnje rezultate. Kljucne rijeci: perkutana laserska dekompresija diska, diskektomija, lumbalna radikularna bol, protruzija diska
The personalization of pain treatment in intensive care units was developed due to the interindividual variability and heterogeneity of critically ill patients. A personalized approach to pain is ...based on the prediction and continuous assessment of pain. In critically ill patients, this approach includes the knowledge of the underlying cause of pain related to the primary diagnosis, the causes of procedural pain and previous chronic pain conditions of the patient, in order to apply a specific therapeutic approach. Available treatment recommendations emphasize the use of adaptive or dynamic analgesia, with titration of analgesics according to changes in the clinical state of patients. They indicate the necessity of pain assessment with tools for pain intensity assessment and therapy evaluation, as well as the need for assessment at regular time intervals. Despite treatment guidelines, clinical practice shows significant deviations from evidence-based recommendations. The reasons are primarily the non-recognition of pain, insufficient knowledge of analgesics (type and dose), lack of regular assessment and inadequacy of the applied tools for pain assessment. In terms of personalization, there is a need to develop objective pain assessment methods, such as sensitive and pain-specific tools that do not rely on the patient's ability to communicate and are independent of assessors, disease characteristics and pharmacological interventions in critically ill patients. Key words:pain; nociception; personalization; monitoring; intensive care medicine Personalizacija lijecenja boli u Jedinicama intenzivne medicine svoje izvoriste nalazi u interindividualnoj varijabilnosti i heterogenosti kriticno oboljelih. Personalizirani pristup boli temelji se na predvidanju i kontinuiranoj procjeni boli. Kod kriticno oboljelih obuhvaca poznavanje osnovnog uzroka boli vezanog uz glavnu dijagnozu, uzroke proceduralne boli kao i prethodna kronicna bolna stanja oboljelog kako bi se primijenio specificni terapijski pristup. Dostupne preporuke za lijecenje naglasavaju primjenu adaptivne ili dinamicke analgezije, sa titracijom analgetika u odnosu na promjenu klinicke situacije pacijenata. One ukazuju na neophodnost procjene boli alatima za procjenu jacine boli i evaluaciju terapije, tako i potrebu procjene u regularnim vremenskim intervalima.Unatoc smjernicama za lijecenje klinicka praksa pokazuje znacajna odstupanja od preporuka temeljenih na dokazima. Razlozi su primarno prisutni u neprepoznavanju boli, nedostatnom poznavanju analgetika (tip i doza), neregularnoj procjeni i neadekvatnosti primijenjenih alata za procjenu boli. U smislu personalizacije namece se potreba razvoja objektivnih metoda procjene boli, alata osjetljivih i specificnih za bol koji se ne oslanjaju na sposobnost komunikacije od strane bolesnika, neovisni su od procjenitelja, karakteristika bolesti, te farmakoloskih intervencija kod kriticno oboljelih. Kljucne rijeci: bol, nocicepcija, personalizacija, monitoring, intenzivna medicina
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.
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