DELIRIUM IN ORTHOPEDIC SURGERY: RISK FACTORS, PROPHYLAXIS AND INTENSIVE CARE.

Postoperative delirium is common in elderly patients. It increases mortality, duration of hospital stay, promotes disability, reduces the quality of life and independence. In this review, we summarize the scientific literature on epidemiology, assessment, pathogenesis, prophylaxis and treatment of deliriumfollowed after orthopedic surgery.

[Effects of epidural anesthesia on stress-induced immune supression during major corrective spine surgery].

STUDY DESIGN: A prospective, randomized study wias performed to compare two anesthetic methods. OBJECTIVE: To evaluate the effect of epidural analgesia on postoperative pain, endocrine- metabolic and inflammatory stress response and cellular inmmune responses during major corrective spine surgetry. METHODS: The study included 350 patients aged 15 to 65 who were randomly allocated to two equal groups. Group I (n=205) had continuous epidural analgesia (E4) and sevoflurane anesthesia during surgety and continuous epidural analgesia with ropivacaine and fentanil after surgery; Group 2 (n= 145) had general anesthesia with sevoflurane and fentanil and systemic administration of opioids after surgery. Patient pain, PONV syndrome, mobility, and satisfaction were measured after surgery along with plasma levels ofcortisol, ghmcose, interleukins IL-1ß, IL-6, and IL-10 during and after surgemy C-reactive protein (CRP), and cell-surface receptor expression of immune cells (cluster of differentiation) HLA-DR+/CD3-, HLA-DR+/CD3+, HILA-DR, CD3, CD4, CD8, CD16, CD19 CD16/56+, and CD16/56+/CD3+) were measured perioperatively. RESULTS: In group 1, there were significantly less pain, less nausea, earlier mobility, and higher satisfaction than those in group 2. Group I has also demonstrated significantly less plasma levels of glucose, cortisol, CRP, IL-lß, IL-6, IL-10 at various stages. The ratio of CD4/CD8 (p=0.001) and B cells (p=0.01) have increased by postoperative day 3 in group 1. NK-cells (CD16/56+) have decreased significantly by day 3 after surgery (p=0.001) compared to the group 2. T-lymphocytes, (CD3) have decreased in all patients, but they were significantly lower in patients receiving opioids, compared wiith EA. CONCLUSIONS: Polerfulr afferent stimulation in major corrective spine surgery accompanied by immunosuppression for at least a wieek after surgery. EA reduces the surgical stress response, prevents postoperative lymphocyte apoptosis and thus, increases stress and infectious resistance.

[Haemostasis disturbances as the component of the surgical stress-response and possibilities of their correction].

OBJECTIVE: An estimation of haemostasis parameters in the major abdominal surgery in comparision with surgical stress-response markers depending on anaesthesia and analgesia technique. METHODS: 120 patients scheduled to undergo elective low-abdominal surgery were allocated to receive either general anaesthesia (n=40) or combined (general + epidural (n=40) or general + spinal (n=40)) anaesthesia. Postoperative analgesia, glucose, cortisol and cytokine levels, as well as coagulation, fibrinolysis, thrombocyte aggregation parameters were estimated. RESULTS: The epidural anaesthesia provided better postoperative analgesia. However both spinal and epidural anaesthesia show comparable correction of surgical stress-response markers. Also both types of regional anaesthesia reduced hypercoagulation expression and prevented fibrinolysis activation. This resulted in a reduction in the hemotransfusion frequency CONCLUSION: Hemostasis changes can be considered as a component of the surgical stress-response. The role of intraoperative regional anaesthesia is much more significant, than postoperative analgesia.

[Postoperative analgesia in abdominal surgery: a new look at an old problem]. / Posleoperatsionnoe obezbolivanie v abdominal'noi khirurgii: novyi vzgliad na staruiu problemu.

Analgesia in abdominal surgery is a sufficiently complicated problem. The extensive surgeries in the abdominal cavity are concomitant with massive tissue damages and are associated the systematic tissue inflammatory response to an intensity of the pain syndrome and of other postoperative complications. The modern understanding of surgical-trauma pathophysiology is indicative of the necessity to modulate the systemic inflammatory response whose severity is preconditioned not only by postoperative pain intensity but also by surgical results. With respect to the above stated, multi-model analgesia can be regarded as an optimal technique since it presupposes the long-term administration of local anesthetics (preferably 0.2% ropivakain) concurrently with non-steroid anti-inflammatory drugs used preoperatively (the most effective one is lornoxicam).

[Diprivan-EDTA--choice in favor of patients safety]. / Diprivan-EDTA--vybor v pol'zu bezopasnosti patsientov.

Use of propofol in anesthesiology increases with every year. On the other hand, some data indicate a risk of postoperative complications caused by bacterial contamination of propofol solution in the course of its utilization. The probability of these complications reaches 6.3%. A modified formula of propofol (diprivan-EDTA) has been developed, which is characterized by antibacterial (bacteriostatic) effect towards 20 most prevalent microorganisms. Preliminary results of clinical evaluation of diprivan-EDTA safety indicate its positive effect on the incidence of severe postoperative complications and mortality of patients in intensive care wards.

[Ropivacaine (naropin), local anesthetic of choice for epidural blockade]. / Ropivakain (naropin) -- mestnyi anestetik vybora pri lechebnykh épidural'nykh blokadakh.

The purpose of this study, carried out in 132 patients with intense acute radicular pain, was search for an optimal local anesthetic to be used in combination with a steroid for therapeutic epidural blockade. Comparative analysis of analgesia attained by epidural injections of 5 ml 2% lidocaine, 4 ml 0.5% bupivacaine, and 4 ml 1% ropivacaine showed the advantages of the latter drug in stable arrest of radicular pain immediately after injection. The duration of analgesia after blockade was 1.4 +/- 0.5, 3.1 +/- 0.3, and 9.5 +/- 1.2 h, respectively. Use of ropivacaine eliminated the main shortcoming of epidural blockade in the treatment of patients with radicular pain, consisting in temporary pain relapse after discontinuation of the local anesthetic effect before development of antiinflammatory effect of the steroid.

[The adequacy of patient protection from surgical trauma under spinal anesthesia]. / Adekvatnost' zashchity bol'nykh ot operatsionnoi travmy v usloviiakh spinal'noi anestezii.

Efficiency of various methods of anesthesia in prevention of the CNS segmented structures hyperreactivity induced by surgical trauma ware studied in 554 patients during planned orthopedic operations and operations on the pelvic organs. Spinal anesthesia played the crucial role in prevention of induced hyperreactivity of nociceptive neurons of the posterior spinal horns. A notable alleviation of postoperative pain in patients operated on under spinal anesthesia was a clinical confirmation of this fact. Analysis of the time course of the amplitudes of the control and test H-reflexes before and after the intervention showed that spinal anesthesia largely prevented perioperative changes in the spinal neuromotor stimulation and, from this viewpoint, can be regarded as the optimal method of anesthesia in surgery on the lower part of the trunk.

EMG responses in humans during painful heterosegmentary stimulation.

The amplitude-temporal parameters of the nociceptive flexor reflex evoked in the upper and lower extremities by painful heterosegmentary electrical stimulation were studied in healthy volunteers. This reflex was detected bilaterally in the muscles of the upper and lower extremities independently of the site of painful stimulation. The maximum amplitude of the reflex was observed in the case, when the segmentary muscle innervation and the application site of painful stimulation coincided. The least latency of the nociceptive flexor reflex was observed after painful stimulation of the ear lobe. It was concluded that nociceptive flexor reflex is not an elementary polysynaptic spinal reaction, but involves also some supraspinal centers.

[Prevention of postoperative pain: pathogenetic bases and clinical aspects]. / Profilaktika posleoperatsionnoi boli: patogeneticheskie osnovy i klinicheskoe primenenie.

The trial aimed at development of pathogenetically sound complex of therapeutic measures to prevent postoperative pain or relieve it significantly included 1912 patients after elective surgical interventions on the lower part of the body. It is shown that basic factors in postoperative pain prevention are the following: a) adequate relief of preoperative pain syndrome; b) use of spinal or spinal-epidural anesthesia as the leading anesthesia method; c) preoperative epidural administration of opioid analgetic drugs; d) pre-, intra- and postoperative administrations of drugs affecting N-methyl-D-aspartate-receptors (ketamine, magnesium sulphate) as well as inhibitors of kininogenesis and prostaglandinogenesis. The success lies in a multimodality approach to prevention of postoperative pain syndrome, i.e. maximal eradication of all the factors promoting onset of pain during pre-, intra- and postoperative period with a simultaneous impact on peripheral and central mechanisms of acute pain. Such an approach resulted in a complete prevention of postoperative pain in 46.2% patients while the rest patients had much less intensive pain.

[Peculiarities of diagnosis and treatment for diabetic feet]. / Osobennosti diagnostiki i lecheniia diabeticheskikh porazhenii stop.

Multifactorial pathogenesis of the "diabetic foot" syndrome suggests advisability to single out some clinical pathogenetic forms, depending on basic causes of the lesions: due to neuropathy, osteoarthropathy, neuro-ischemic factors. The authors has developed the algorithm which enables to diagnose various forms of the syndrome and differentiate the treatment. The most important treatment modalities include unloading and podiatric measures as well as surgery, systemic antibacterial and glucolytic therapy. Conservative or surgical antiischemic measures are indicated only in demonstration of the degree of the ischemic damage in the lower extremities by Doppler ultrasonography and measurement of local oxygenation of the skin. The combined differentiated treatment in 142 patients with diabetic lesions of the feet has resulted 97.2% favourable outcomes in neuropathy and 86.5% successful outcomes in neuroischemic damages. Local oxygenation of dorsal skin of the foot (< 20 mm Hg) indicates that amputation above the ankle is highly probable.

[Anesthesia in surgical treatment of pyo-necrotic forms of diabetic foot]. / Obezbolivanie pri khirurgicheskom lechenii gnoino-nekroticheskikh form "diabeticheski stopy".

Examinations of 48 patients with the syndrome of "diabetic foot" (IV-V degree according to Wagner classification), have shown advantages of prolonged epidural anesthesia (EA) carried out during pre-, intra-, and postoperative (6-7 days) period. This method has relieved pain during postoperative period with minimal impact on carbohydrate metabolism and central hemodynamics. Moreover prolonged EA is a basic prophylactic method against the development of phantom painful syndrome in patients with amputated extremity. The prolonged postoperative EA is a reliable method for modification of surgical stress-response, being especially important in patient, afflicted with a severe form of diabetes mellitus who represent a high surgical and anesthesiological risk group.

[Current principles of multidisciplinary treatment of pain in orthopedic clinics]. / Sovremennye printsipy mul'tidistsiplinarnogo lecheniia boli v ortopedicheskoi klinike.

Differentiated strategy of treating patients with acute and chronic pain is developed. Preemptive analgesia is a priority trend in the treatment of acute postoperative pain. The most prevalent method of postoperative analgesia is prolonged opioid epidural analgesia carried out in intensive care wards and other wards by an acute pain management team. For treating patients with chronic painful syndromes, protocols of initial clinical and diagnostic evaluation are developed, permitting the choice of individual treatment strategy. Differentiated complex drug therapy planned with consideration for individual course of the painful syndrome is the basis of treating patients with phantom pain syndrome. Algorithms of differentiated therapy of radicular and spondylogenic pain are designed. Stage-by-stage analysis of treatment efficacy is carried out using modern electrophysiological methods. Realization of the proposed organization principles improved the efficacy of postoperative analgesia to 88.2%, prevented the development of postoperative painful syndrome in 35.6% cases, decreased the incidence of phantom pain syndrome after amputation of the limb from 63.3 to 31.6% and increased the efficacy of this syndrome treatment to 70.1%, and increased the efficacy of treating vertebrogenic painful syndromes to 82.3%.

[The treatment of the phantom pain syndrome with tizanidine]. / Lechenie fantomno-bolevogo sindroma tizanidinom.

The authors carried out estimation of analgetic effect of tisanidin by double blind test in patients with phantom limb pain syndrome. 14 patients took the medicine in a dose of 12 mg/day and 5 patients took placebo at the same dose. Characteristics and intensity of pain were estimated in accordance with McGill pain questionnaire and visual analogue scale. Pain possessed more than one sensory characteristics in the majority of patients. Tisanidin had a significant analgetic influence on all type of phantom limb pain: "neuralgic"--acute, shooting, transitory, "causalgic"--hot, burning, searing, "cramping" pain. Pain sensation did not decrease only in one of 14 patients treated with tisanidin. The authors explain the effectivity of the drug for treatment of phantom limb pain of different sensory modality by variety of the mechanisms of its therapeutic action, the capacity to decrease the releasing of excitatory neurotransmitter amino acids and the influence on alpha 2-adrenoceptors.