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ABSTRACT: Complex regional pain syndrome I (CRPS I) is a frequent and debilitating condition with unclear etiology. Hypothesizing that maladaptive central processes play a crucial role in CRPS, the current study set out to explore cerebral activation during a task to suppress the feeling of pain under constant painful stimulation.
Ten individuals with CRPS I with symptoms on their left hand were subjected to electrical stimulation of both index fingers subsequently in a functional magnetic resonance imaging experiment. Their data were compared with 15 healthy controls.
Concerning psychophysical measures, patients succeeded similarly as healthy controls in suppressing the feeling of pain. However, during constant painful stimulation and with the task to suppress the feeling of pain, there were significant differences in the interaction analyses of the corresponding cortical activation.
Patients differ from healthy controls by the activation pattern of cerebral areas that belong to the descending opioid pain suppression pathway: PAG and cingulate cortex are activated significantly less during suppression of pain, regardless of whether the symptomatic or asymptomatic hand was stimulated. Thus, there is a generalized functional change in individuals with CRPS I. However, it cannot be deducted whether the abnormality is causative or merely an effect, possibly maladaptive.
The Clinical journal of pain 05/2011; 27(9):796-804. · 3.01 Impact Factor
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ABSTRACT: Although the etiology of complex regional pain syndrome type 1 (CRPS 1) is still debated, many arguments favor central maladaptive changes in pain processing as an important causative factor.
To look for the suspected alterations, 10 patients with CRPS affecting the left hand were explored with functional magnetic resonance imaging during graded electrical painful stimulation of both hands subsequently and compared with healthy participants.
Activation of the anterior insula, posterior cingulate cortex (PCC), and caudate nucleus was seen in patients during painful stimulation. Compared with controls, CRPS patients had stronger activation of the PCC during painful stimulation of the symptomatic hand. The comparison of insular/opercular activation between controls and patients with CRPS I during painful stimulation showed stronger (posterior) opercular activation in controls than in patients.
Stronger PCC activation during painful stimulation may be interpreted as a correlate of motor inhibition during painful stimuli different from controls. Also, the decreased opercular activation in CRPS patients shows less sensory-discriminative processing of painful stimuli.These results show that changed cerebral pain processing in CRPS patients is less sensory-discriminative but more motor inhibition during painful stimuli. These changes are not limited to the diseased side but show generalized alterations of cerebral pain processing in chronic pain patients.
The Clinical journal of pain 05/2010; 26(4):339-47. · 3.01 Impact Factor
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ABSTRACT: Hepatic hypoperfusion is regarded as an important factor in the pathophysiology of perioperative liver injury. Although epidural anesthesia (EDA) is a widely used technique, no data are available about the effects on hepatic blood flow of thoracic EDA with blockade restricted to thoracic segments in humans.
In 20 patients under general anesthesia, we assessed hepatic blood flow index in the right and middle hepatic vein by use of multiplane transesophageal echocardiography before and after induction of EDA. The epidural catheter was inserted at TH7-9, and mepivacaine 1% with a median (range) dose of 10 (8-16) mL was injected. Norepinephrine (NE) was continuously administered to patients who demonstrated a decrease in mean arterial blood pressure below 60 mm Hg after induction of EDA (EDA-NE group). The other patients did not receive any catecholamine during the study period (EDA group). A further 10 patients without EDA served as controls (control group).
In five patients, administration of NE was necessary to avoid a decrease in mean arterial blood pressure below 60 mm Hg. Thus, the EDA-NE group consisted of five patients and the EDA group of 15. In the EDA group, EDA was associated with a median decrease in hepatic blood flow index of 24% in both hepatic veins (P < 0.01). In the EDA-NE group, all five patients showed a decrease in the blood flow index of the right (median decrease 39 [11-45] %) and middle hepatic vein (median decrease 32 [7-49] %). Patients in the control group showed a constant blood flow index in both hepatic veins. Reduction in blood flow index in the EDA group and the EDA-NE group was significant in comparison with the control group (P < 0.05). In contrast to hepatic blood flow, cardiac output was not affected by EDA.
We conclude that, in humans, thoracic EDA is associated with a decrease in hepatic blood flow. Thoracic EDA combined with continuous infusion of NE seems to result in a further decrease in hepatic blood flow.
Anesthesia and analgesia 04/2009; 108(4):1331-7. · 3.08 Impact Factor
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ABSTRACT: Fast-track recovery programs have led to reduced patient morbidity and mortality after major surgery. In terms of elective open infrarenal aneurysm repair, no evidence is available about such programs. To address this issue, we have conducted a randomized prospective pilot study.
The study involved prospective randomization of 101 patients with the indication for elective open aneurysm repair in a traditional and a fast-track treatment arm. The basic fast-track elements were no bowel preparation, reduced preoperative fasting, patient-controlled epidural analgesia (PCEA), enhanced postoperative feeding, and postoperative mobilization. Morbidity and mortality, need for postoperative mechanical ventilation, length of stay (LOS) in the intensive care unit (ICU) and total length of postoperative hospital stay were analyzed in terms of an intention to treat.
Demographic data for the two groups were similar. In the fast-track group the need for postoperative ventilation was significantly lower (6.1% versus 32%; p = 0.002), the median LOS on ICU did not significantly differ (20 h versus 32 h; p = 0.183), full enteral feeding was achieved significantly earlier (5 versus 7 days; p < 0.0001), and the rate of postoperative medical complications-gastrointestinal, cardiac, pulmonary, renal, and infective-was significantly lower (16% versus 36%; p = 0.039). The postoperative hospital stay was significantly shorter in the fast-track group (10 days versus 11 days; p = 0.016); the mortality rate in both groups was 0%.
An optimized patient care program in open infrarenal aortic aneurysm repair shows favorable results concerning need for postoperative assisted mechanical ventilation, time to full enteral feeding, and incidence of medical complications. Further ranomized multicentric trials are necessary to justify broad implementation (clinical trials. gov identifier NCT 00615888).
World Journal of Surgery 02/2009; 33(3):577-85. · 2.36 Impact Factor
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ABSTRACT: Fast track programs, multimodal therapy strategies, have been introduced in many surgical fields to minimize postoperative morbidity and mortality. In terms of lung resections no randomized controlled trials exist to evaluate such patient care programs.
In a prospective, randomized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared. Main differences between the two groups consisted in preoperative fasting (6h vs 2h) and analgesia (patient controlled analgesia vs patient controlled epidural analgesia). Study endpoints were pulmonary complications (pneumonia, atelectasis, prolonged air leak), overall morbidity and mortality. Analysis was performed in an intention to treat.
Both study groups were similar in terms of age, sex, preoperative forced expiratory volume in one second (FEV(1)), American Society of Anesthesiologists score and operations performed. The rate of postoperative pulmonary complications was 35% in the conservative and 6.6% in the fast track group (p=0.009). A subgroup of patients with reduced preoperative FEV(1) (<75% of predicted value) experienced less pulmonary complications in the fast track group (55% vs 7%, p=0.023). Overall morbidity was not significantly different (46% vs 26%, p=0.172), mortality was comparable in both groups (4% vs 3%).
We evaluated an optimized patient care program for patients undergoing lung resections in a prospective randomized pilot study. Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery.
European Journal of Cardio-Thoracic Surgery 07/2008; 34(1):174-80. · 2.55 Impact Factor
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ABSTRACT: Fast-track programs have been introduced in many surgical fields to minimize postoperative morbidity and mortality. Morbidity after elective open infrarenal aneurysm repair is as high as 30%; mortality ranges up to 10%. In terms of open infrarenal aneurysm repair, no randomized controlled trials exist to introduce and evaluate such patient care programs.
This study involved prospective randomization of 82 patients in a "traditional" and a "fast-track" treatment arm. Main differences consisted in preoperative bowel washout (none vs. 3 l cleaning solution) and analgesia (patient controlled analgesia vs. patient controlled epidural analgesia). Study endpoints were morbidity and mortality, need for postoperative mechanical ventilation, and length of stay (LOS) on intensive care unit (ICU).
The need for assisted postoperative ventilation was significantly higher in the traditional group (33.3% vs. 5.4%; p = 0.011). Median LOS on ICU was shorter in the fast-track group, 41 vs. 20 h. The rate of postoperative medical complications was significantly lower in the fast-track group, 16.2% vs. 35.7% (p = 0.045).
We introduced and evaluated an optimized patient care program for patients undergoing open infrarenal aortic aneurysm repair which showed a significant advantage for "fast-track" patients in terms of postoperative morbidity.
Langenbeck s Archives of Surgery 06/2008; 393(3):281-7. · 1.81 Impact Factor
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ABSTRACT: To investigate the frequency of bacterial colonization of epidural catheters used for postoperative pain treatment longer than 24 hours in abdominal, thoracic, or trauma surgery patients.
Retrospective study.
Intermediate care facility and general ward of a university hospital.
502 patients who received epidural catheters after abdominal, thoracic, or vascular surgery at our institution from January 1996 to December 2000.
Placement of an epidural catheter, which was used for postoperative pain treatment, for more than 24 hours. The puncture site dressing included saturation each day with povidone-iodine.
Microbiologic monitoring of epidural catheter tips and daily examination of puncture sites with regard to signs of inflammation took place. Four times daily patients were examined to check adequacy of pain treatment and neurologic deficits. Catheter tip cultures were positive in 29 patients (5.8%). Staphylococcus epidermidis was isolated in 22 cases (76%). No case of spinal epidural abscess was observed within 6 months after epidural catheterization. The average catheterization time was 5 days (quartile range: 4 to 6 days).
Meticulous management ensures a relatively low level of bacterial contamination in epidural catheters applied for postoperative pain treatment greater than 5 days. Contamination rarely leads to spinal epidural infection.
Journal of Clinical Anesthesia 04/2004; 16(2):92-7. · 1.21 Impact Factor
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ABSTRACT: In the present work we investigate the analgesic combination of the pyrazole-derivative metamizol and the non-steroidal anti-inflammatory drug diclofenac after trauma surgery with respect to the postoperative opioid consumption (via patient-controlled analgesia (PCA)) in the first 24 h after surgery, and the reduction of pain in the immediate postoperative period. In a double-blind randomized placebo controlled study, 48 patients, scheduled for minor trauma surgery received either metamizol (three doses of 1 g intravenously) and diclofenac (two doses of 100 mg suppository) or placebo beginning immediately preoperatively and repeated postoperatively. Totally the verum group received metamizol 3 g and diclofenac 200 mg. Postoperative pain intensity was measured by the numeric rating scale (NRS). All patients were allowed to order levomethadone from a PCA-pump for 24 h after surgery. Pain scores and opioid consumption were evaluated in the first six postoperative hours, 12 and 24 h after end of surgery. The patients receiving verum had significantly less pain at all points in time except for 2 h and ordered a significantly lower cumulated dose of levomethadone during the first 24 h postoperatively than placebo treated subjects (opioid-sparing effect after 24 h: −74%). There were no significant differences in the incidence of side effects between the two groups. Perioperative application of metamizol and diclofenac results in better pain relief and significantly lowers opioid requirements in patients after minor trauma surgery.
Acute Pain.
