Risk factors associated with vasospasm after non-traumatic subarachnoid hemorrhage: a retrospective analysis of 456 patients.

BACKGROUND: The pathophysiology of vasospasm (VS) after non-traumatic subarachnoid hemorrhage is not completely understood. Several risk factors associated with VS were previously reported, partially with conflicting results. The aim of this study was to identify patients at increased risk for VS. METHODS: Retrospective analysis of data from all patients treated in our institutional intensive care unit (ICU) between 2010 and 2016 after non-traumatic subarachnoid hemorrhage. Possible contributing factors for VS studied were: age, sex, aneurysm-localization, treatment option, ICU-stay, ICU mortality, pre-existing condition, medication history, World Federation of Neurosurgical Societies (WFNS) grading system, modified Fisher scale. RESULTS: We obtained data from 456 patients. 184 were male and 272 female patients, respectively. Mean age was 57.7±13.9 and was not different between sexes. In 119 patients, VS was diagnosed after subarachnoid hemorrhage. Incidence of VS was not different between sexes (male: 22.3%, female: 28.7%, P=0.127). Patients with VS were significantly younger (mean age 52.2 vs. 59.7, P<0.001), meanwhile patients aged 36-40 yrs. had the highest incidence of VS. Most VS were found after rupture of middle cerebral artery-aneurysms. Higher incidence of VS was found after aneurysm clipping compared to coiling. VS developed more often in patients with more severe WFNS grade and Fisher scale. In multivariate analysis, age, previous drug abuse and history of anticoagulants were associated with the incidence of VS. CONCLUSIONS: Younger age, middle cerebral artery-aneurysms, aneurysm clipping, previous drug abuse and history of anticoagulants were associated with a higher incidence of VS after non-traumatic subarachnoid hemorrhage. No gender difference was found.

[Pain management after ambulatory surgery in Germany]. / Ambulante Schmerztherapie - Optimierung der Schmerztherapie nach ambulanten Operationen.

An increasing percentage of surgical procedures are performed in an ambulatory setting. However, a fairly high number of patients experience moderate to severe postoperative pain and pain is a common reason for unanticipated hospital admission. An adequate postoperative pain therapy in the ambulatory setting is therefore essential not only for ethical reasons or improvements in recovery but also for economic reasons but - in Germany - still remains inadequate. The following article deals with the problems that cause inadequat pain therapy after ambulatory surgery in Germany and introduces different therapeutic options, strategies and drugs relevant to optimize pain therapy after ambulatory surgery. Major aspects are education of the patient, the use of adequate non-opioid analgesics and implementation of regional analgesia techniques. Non-opioid analgesics are known to be effective to reduce opioid requirements and side effects; however, not all non-opioid analgesics are similar effective. Furthermore side effects and risks of these drugs need to be considered in individual patients. Benefits from regional anesthesia and analgesia techniques are well known after sugery. Experiences from other countries demonstrate improved analgesia, less side effects (e.g. sedation, insomnia) and increased patients satisfaction associated with continuous peripheral nerve blocks at home. In Germany, these techniques are not frequently used but need to be considered in the future to optimize postoperative pain management after ambulatory surgery.

Acute pain management in patients with fibromyalgia and other diffuse chronic pain syndromes.

PURPOSE OF REVIEW: Patients with fibromyalgia are at increased risk to experience increased and prolonged postoperative pain. In this review, we will provide an overview of pathophysiological characteristics of fibromyalgia relevant for enhanced pain processing after surgery. Furthermore, we will present some potential treatment options in the perioperative period based on specific symptoms of individual fibromyalgia patients to optimize their pain management after surgery. RECENT FINDINGS: Recent evidence points towards enhanced central nervous system sensitization and decreased descending inhibition in patients with fibromyalgia. Even in patients without fibromyalgia, these two mechanisms are seen as major contributors to the severity of acute and chronic pain states after surgery. Furthermore, other symptoms and comorbidities such as anxiety, depression and somatization disorder, frequently associated with fibromyalgia, are independently known to increase the risk of acute and prolonged pain after surgery. Therefore, an optimal treatment approach in the perioperative period should include substances and strategies targeting specific symptoms in fibromyalgia patients to prevent or specifically reduce acute and prolonged pain after surgery. Such multimodal pain management in fibromyalgia patients in the perioperative period should include nonopioid analgesics, gabapentinoids, antidepressants, N-methyl-D-asparate antagonists and use of regional techniques when appropriate. SUMMARY: The perioperative pain management of patients with fibromyalgia is challenging and should include symptom-based approaches to target enhanced central sensitization and decreased inhibition in these patients as well as their psychological syndromes aiming to decrease acute and prolonged pain after surgery.

Progesterone relates to enhanced incisional acute pain and pinprick hyperalgesia in the luteal phase of female volunteers.

The role of sex hormones on postsurgical pain perception is basically unclear. Here, we studied the role of endogenous gonadal hormones for pain and hyperalgesia in human volunteers after experimental incision. A 4-mm incision was made in the volar forearm of 15 female volunteers both in the follicular and the luteal phase (random block design). Somatosensory profiles were assessed at baseline and 1 to 72 hours after incision by quantitative sensory testing, compared between both cycle phases, and related to individual plasma levels of gonadal hormones. Sensory testing at baseline revealed significantly lower pain thresholds (25 vs 46 mN, P < 0.005) and increased pain ratings to pinprick (0.96 vs 0.47, P < 0.0001) in the luteal phase; similarly, 1 hour after incision, pain intensity to incision (38 vs 21/100, P < 0.005), pinprick hyperalgesia by rating (P < 0.05), and area of secondary hyperalgesia (P < 0.001) were enhanced in the luteal phase. Multiple regression analysis revealed that pinprick pain sensitivity at baseline was significantly predicted by progesterone (partial r = 0.67, P < 0.001), follicle-stimulating hormone (FSH) (partial r = 0.61, P < 0.005), and negatively by testosterone (partial r = -0.44, P < 0.05). Likewise, incision-induced pain and pinprick hyperalgesia (rating and area) were significantly predicted by progesterone (partial r = 0.70, r = 0.46, and r = 0.47, respectively; P < 0.05-0.0001) and in part by FSH; the contribution of estrogen, however, was fully occluded by progesterone for all measures. In conclusion, pinprick pain and incision-induced pain and mechanical hyperalgesia were greater in the luteal phase and predicted by progesterone, suggesting a major role for progesterone. Other hormones involved are testosterone (protective) and in part FSH.