Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial.

PURPOSE: Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being. DESIGN: Double-blind randomized controlled trial. METHODS: The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications. FINDINGS: Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present. CONCLUSIONS: This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.

Local Periarticular Infiltration with Dexmedetomidine Results in Superior Patient Well-Being after Total Knee Arthroplasty Compared with Peripheral Nerve Blocks: A Randomized Controlled Clinical Trial with a Follow-Up of Two Years.

BACKGROUND: This study aimed to compare local periarticular infiltration (LIA) with ultra-sound guided regional anesthesia (USRA) with ropivacaine and dexmedetomidine as an additive agent in primary total knee arthroplasty (TKA). METHODS: Fifty patients were randomized into two groups in a 1:1 ratio. Patients in the LIA group received local periarticular infiltration into the knee joint. The USRA group received two single-shot USRA blocks. Functional outcomes and satisfaction (range of movement, Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score, and Forgotten Joint Score), including well-being, were analyzed preoperatively and at five days, six weeks, and one and two years postoperatively. RESULTS: Functional outcomes did not significantly differ between the two groups at six weeks and one and two years after the implementation of TKA. A moderate correlation was observed in the LIA group regarding well-being and pain on day five. Six weeks postoperatively, the LIA group showed significantly superior well-being but worse pain scores. No differences between the groups in well-being and functional outcomes could be observed one and two years postoperatively. CONCLUSION: Patients treated with LIA had superior postoperative well-being in the early postoperative phase of up to six weeks. Furthermore, LIA patients had similar functionality compared to patients treated with USRA but experienced significantly more pain six weeks postoperatively. LIA leads to improved short-term well-being, which is potentially beneficial for faster knee recovery. We believe that LIA benefits fast-track knee recovery with respect to improved short-term well-being, higher practicability, and faster application.

Combined femoral and popliteal nerve block is superior to local periarticular infiltration anaesthesia for postoperative pain control after total knee arthroplasty.

INTRODUCTION: After primary total knee arthroplasty (TKA), local periarticular infiltration anaesthesia (LIA) is a fast and safe method for postoperative pain control. Moreover, ultrasound-guided regional anaesthesia (USRA) with femoral and popliteal block is a standard procedure in perioperative care. Two analgesic regimens for TKA-LIA versus URSA with dexmedetomidine-were compared as an additive to ropivacaine. We hypothesised that the use of URSA provides a superior opioid sparing effect for TKA compared with LIA. METHODS: Fifty patients (planned 188 participants; safety analysis was performed after examining the first 50 participants) were randomised. These patients received LIA into the knee capsule during surgery with 60 ml of ropivacaine 0.5% and 1 ml of dexmedetomidine (100 µg ml-1) or two single-shot URSA blocks (femoral and popliteal block) before surgery with 15 ml of ropivacaine 0.5% and 0.5 ml of dexmedetomidine for each block. Postoperative opioid consumption in the first 48 h, pain assessment and complications were analysed. RESULTS: In the safety analysis, there was a significantly higher need for opioids in the LIA group, with a median oral morphine equivalent of 42.0 [interquartile range (IQR) 23.5-57.0] mg versus 27.0 [IQR 0.0-33.5] mg (P = 0.022). Due to this finding, the study was terminated for ethical considerations according to the protocol. CONCLUSION: This is the first study presenting data on LIA application in combination with dexmedetomidine. A superior opioid-sparing effect of URSA was observed when compared with LIA in TKA when dexmedetomidine is added to local anaesthetics. Also, a longer lasting opioid-sparing effect in the LIA group was observed when compared with the recently published literature; this difference could be attributed to the addition of dexmedetomidine. Therefore, multimodal analgesia regimens could be further improved when LIA or USRA techniques are combined with dexmedetomidine.

The Austrian ICU survey : A questionnaire-based evaluation of intensive care medicine in Austria.

BACKGROUND: While structures of intensive care medicine in Austria are well defined, data on organisational and medical practice in intensive care units (ICUs) have not been systematically evaluated. METHODS: In this explorative survey, organisational and medical details of ICUs in Austria were collected using an online questionnaire consisting of 147 questions. RESULTS: Out of 249 registered ICUs 73 (29.3%) responded, 60 were adult, 10 pediatric/neonatal ICUs and 19, 25 and 16 ICUs were located in level I, II and III hospitals, respectively. Of the respondents 89% reported that the ICU director was board-certified in intensive care medicine. Consultants were constantly present in 78% of ICUs during routine working hours and in 45% during nights and weekends. The nurse:bed ratio varied between 1:1 and 1:2 in 74% during day shifts and 60% during night shifts. Routine physiotherapist rounds were reported to take place daily except weekends in 67% of ICUs. Common monitoring techniques were reported to be in routine or occasional use in 85% and 83% of ICUs, respectively. The majority of ICUs provided daily visiting hours ranging between 2-12 h. Waiting rooms for relatives were available in 66% and an electronic documentation system in 66% of ICUs. Written protocols were available in 70% of ICUs. CONCLUSION: The Austrian ICU survey suggests that ICUs in Austria are clearly structured, well-organized and well-equipped and have a high nurse:bed ratio. In view of the relatively low return rate we cannot exclude that a selection bias has led to overestimation of the survey findings.

[Post-polio Syndrome in the Perioperative Phase]. / Das Post-Polio-Syndrom in der perioperativen Phase.

Due to the numerous poliomyelitis epidemics that have continued over the last decades and the post-polio syndrome (PPS) that occurs 10 - 30 years after poliomyelitis infection, the prevalence of PPS is also expected to increase in Europe. At the same time, due to the musculoskeletal disorders associated with the underlying disease, PPS patients often require surgery for which special anaesthetic requirements must be taken into account. In this analysis we summarise the current evidence and recommendations.

Adsorption therapy in critically ill with septic shock and acute kidney injury: a retrospective and prospective cohort study.

BACKGROUND: Haemoadsorption has been described as an effective way to control increased pro- and anti-inflammatory mediators ("cytokine storm") in septic shock patients. No prospective or randomised clinical study has yet confirmed these results. However, no study has yet prospectively specifically investigated patients in severe septic shock with sepsis-associated acute kidney injury (SA-AKI). Therefore, we aimed to examine whether haemoadsorption could influence intensive care unit (ICU) and hospital mortality in these patients. Furthermore, we examined the influence of haemoadsorption on length of stay in the ICU and therapeutic support. METHODS: Retrospective control group and prospective intervention group design in a tertiary hospital in central Europe (Germany). Intervention was the implementation of haemoadsorption for patients in septic shock with SA-AKI. 76 patients were included in this analysis. RESULTS: Severity of illness as depicted by APACHE II was higher in patients treated with haemoadsorption. Risk-adjusted ICU mortality rates (O/E ratios) did not differ significantly between the groups (0.80 vs. 0.83). We observed in patients treated with haemoadsorption a shorter LOS and shorter therapeutic support such as catecholamine dependency and duration of RRT. However, in multivariate analysis (logistic regression for mortality, competing risk for LOS), we found no significant differences between the two groups. CONCLUSIONS: The implementation of haemoadsorption for patients in septic shock with acute renal failure did not lead to a reduction in ICU or hospital mortality rates. Despite univariate analysis delivering some evidence for a shorter duration of ICU-related treatments in the haemoadsorption group, these results did not remain significant in multivariate analysis. Trial registration CytoSorb® registry https://clinicaltrials.gov/ct2/show/NCT02312024 . December 9, 2014. DATABASE: https://www.cytosorb-registry.org/ (registration for content acquisition is necessary).

Adult patients' wellbeing and disturbances during early recovery in the post anaesthesia care unit. A cross-sectional study.

OBJECTIVES: Assessment of patients' wellbeing in the post anaesthesia care unit and how much each disturbance influences it. Furthermore, assessment of the incidence of the correlated disturbances and whether there are gender-specific aspects. DESIGN/SETTING: Observational anonymised survey with a validated questionnaire in a university hospital in central Europe. MAIN OUTCOME MEASURES: Incidence rates of wellbeing and disturbances in the post anaesthesia care unit. RESULTS: The patients' most frequently reported early postsurgical disturbances (n = 349) were i) dry mouth (35.4%), ii) pain in the surgical area (12.7%) and iii) hunger (12.2%). Every other disturbance was below 10% (e.g. nausea). Subjective wellbeing was reported by 57.2% of our patients. There were weak correlations between wellbeing and physical discomfort, pain in the surgical area, sleepiness and nausea. The strongest correlation was with physical discomfort. Female patients showed more feelings of cold, nausea and headache. CONCLUSION: Even in hospitals repeatedly certified in pain management, a high percentage of patients still claim early postoperative discomfort. We see the necessity for an increased focus on this topic and the need for investigations regarding patients' perception. The most frequent claims were related to pain in the surgical area and a dry mouth.

[Severe Shock Symptoms Due to Ticagrelor Related Anaphylactoid Reaction Following ST Elevation Myocardial Infarction]. / Schwere Schocksymptomatik infolge anaphylaktoider Reaktion auf Ticagrelor.

BACKGROUND: Ticagrelor as a P2Y12 receptor antagonist is recommended in patients with acute coronary syndrome without a primary cardiosurgical therapy. Severe relevant side effects, especially anaphylactic reactions, have not yet been described in the current literature. CASE PRESENTATION: We describe the first documented case in the current literature with a severe anaphylaxis after ticagrelor in a 76-year-old male patient with ST-elevation myocardial infarction. The diagnosis seems to be objectivated by the observed time-related life-threatening event after repetitive administration of ticagrelor and the rapid stabilization after adequate anaphylactic treatment. CONCLUSION: This case should raise the awareness that a supposedly safe drug can still cause an anaphylactic shock.