PAIN SYNDROME IN PATIENTS AFTER COMBINED OPERATIONS FOR COMBINED ANORECTAL DISEASES USING MODERN SURGICAL TECHNOLOGIES.

OBJECTIVE: The aim: To compare the pain in patients with combined pathology of the anal canal and rectum after combined operations using modern high-frequency electrosurgical and radio-surgical devices and a conventional metal scalpel. PATIENTS AND METHODS: Materials and methods: The results of treatment of 635 patients with combined pathology of the anal canal and rectum using high-frequency electrosurgery and radio-wave surgery, which were divided into 4 study groups, as well as 112 patients using a metal surgical scalpel were analyzed. RESULTS: Results: Assessing the pain syndrome on the first day of the postoperative period, it was found that it was most pronounced in control group patients, where the need for anal¬gesia 2 % promedol solution was 4±1 ml and in the first, third and fourth study groups patients needed for analgesia 2±1 ml of 2 % promedol solution when using "Surgitron" radio-wave surgery device, "EFA" and "KLS Martin" high-frequency electrosurgical devices respectively. When using device "ERBE ICC 200", the need for a 2 % promedol solution for analgesia was 3±1 ml. CONCLUSION: Conclusions: Using of radio-wave surgery device and high-frequency electrosurgery devices is much better compared to the use of a surgical metal scalpel because they cause much less pain due to the formation of a thin layer of coagulation necrosis, promoting the formation of a delicate elastic scar and preventing formation of scar anal strictures.

Changes in Respiratory Function during Treatment with Combination of Analgesic Substances Trimeperidine and Dexmedetomidine.

The effects of analgesic substances trimeperidine and dexmedetomidine and their combinations in different proportions (0.75:0.25, 0.5:0.5, 0.25:0.75 of the medium effective doses of each substance) on respiratory function was studied in experiments on rats. Administration of substances in 1 ED50 by analgesic effect (corresponded to medium therapeutic dose of trimeperidine in humans) was characterized by significantly longer suppression of respiration over 90 min in comparison with combined treatment with these substances. Administration of the substances in a dose of 8 ED50 by analgesic effect (corresponded to daily therapeutic dose) over 60 min was followed by more than 3-fold reduction in respiration frequency and respiratory minute volume, more pronounced in animals receiving trimeperidine. Combined administration of these drugs in the specifi ed dose induced less pronounced suppression of respiration and combined administration of trimeperidine and dexmedetomidine in proportion of 0.75:0.25 signifi cantly reduced the period of restoration of respiratory parameters in comparison with animals receiving single substances.

POST-ANESTHETIC REHABILITATION PERIODS AND ANESTHESIA DOSAGE FOR LAPAROSCOPIC CHOLECYSTECTOMY: RELATIONSHIP TO THE TOTAL OXIDATIVE CAPACITY OF LIVER.

Analysis of the results of pharmacological phenotyping using antipyrine test prior to providing anesthesia for laparoscopic cholecystectomy showed that trimeperidine (promedol) dosing with allowance for the total oxidative capacity of liver and the patient mass allows the periods of post-anesthetic rehabilitation to be controlled. Clear algorithm of trimeperidine dosing based on established indices of the total oxidative capacity of liver and is yet nor developed because of restricted sampling set. The obtained results show expediency of using and studying antipyrine test as a simple, cheap, and informative method of individual anesthesia dosing for increasing the adequacy of general anesthesia.

[SEROTONERGIC REGULATION OF THE DUODENUM CONTRACTIONS].

The review contains an analysis of literature data on enhancement mechanisms of duodenum contractions arising during stimulation of the sympathetic trunk in the right thoracic cavity in dogs. It is established in experiments that There are mostly enhancement, not relaxation of the organ contraction occured. In this case the stimulatory effect due to the excitation of the parasympathetic fibers is excluded. The trimeperedin inhibit the serotonin receptors of autonomic ganglia neurons stimulatory activity during the nerve stimulation. It is concluded that the sympathetic trunk contain the preganglionic serotonergic nerve fibers, whose activation leads to increased bowel contractions. Direct adipinate-serotonin administration increased the bowel contraction that confirm the preganglionic serotonergic nerve fibers presence in the sympathetic trunk. The practical significance of these studies is that the new approach to the development of pharmacological agents to stimulate the motility of the gastrointestinal tract was found. The trimeperedin may inhibit the serotoninergic nerves activity that resulted in the perioperative constipation in surgical patients. Practical recommendation to exclude trimeperedin in preparing the patient for surgery to prevent perioperative constipation is formulated.

[Periods of post-anesthetic rehabilitation and anesthesia dosage for laparoscopic cholecystectomy: retrospective investigation].

A retrospective descriptive nonrandomized cohort study of 585 anesthesia cards of patients who had undergone planned laparoscopic cholecystectomy showed no effect of the patient age and sex on the length of post-anesthetic rehabilitation period. The doses of sodium thiopental, ketamine, and trimeperidine affect the length of these periods by no more than 12%. Further search for and studying of factors affecting the duration of post-anesthetic rehabilitation is required in order to improve the safety and adequacy of general anesthesia.

[Analgesia in hemophiliac patients during orthopedic surgery].

AIM: To develop an effective and safe analgesic regimen (by minimizing the proportion of narcotic analgesics) in hemophiliac patients in the perioperative period during high-trauma surgeries (total knee and hip replacements). SUBJECTS AND METHODS: The prospective study included 24 patients aged 22 to 57 years (median age 38 years) with severe congenital hemophilia A (n = 22) and B (n = 2), who had undergone knee (n = 18) or hip (n = 6) replacements in the Hematology Research Center, Russian Ministry of Health of the Russian Federation, in 2013. Two analgesic regimens (a) paracetamol with trimeperidine; b) paracetamol and ketamine with trimeperidine) were used. To assess pain intensity, the authors used scoring scales: a visual analogue scale (VAS) and a numeric rating scale (NRS). The effect of paracetamol on hemostasis was evaluated on the basis of thromboelastogram and coagulogram readings. Possible paracetamol hepatotoxicity was assessed analyzing liver enzymes. RESULTS: An interview has shown that 66% of the hemophiliac patients regularly take analgesics for chronic pain syndrome, among them 29% use narcotic analgesics. It is difficult to achieve perioperative analgesia in these patients. The dosage of narcotics can be decreased (that of trimeperidine on an average from 80 to 45 mg/day) in the early postoperative period if non-narcotic analgesics, such as paracetamol 4 g/day, are incorporated into the analgesic regimen. Paracetamol promotes pain relief to moderate and mild (not more than 40-50 VAS scores and 3-4 NRS scores), without affecting hemostasis (the thromboelastogram readings differed statistically insignificantly; the coagulation index was 0.6-1.6) and without having a hepatotoxic effect. CONCLUSION: The systemic use of analgesics in hemophiliac patients considerably makes postoperative analgesia difficult. The use of paracetamol with trimeperidine within the first 24 hours after high-trauma surgeries in hemophiliac patients (even if they have hepatitis C) is rather effective and safe.

[Thrombocytopenia and postoperative analgesia].

OBJECTIVE: To develop effective and safe measures of postoperative multimodal analgesia (optimizing the use of narcotic analgesics) in surgical treatment of hematological patients with thrombocytopenia. DESIGN: A pilot and prospective comparative controlled study. METHODS: We studied 27 patients with acquired thrombocytopenia who underwent laparoscopic splenectomy. Three schemes of anesthesia were used: 1) Nefopam 20 mg/day + trimeperidin (n = 7); 2) Paracetamol 4 g/day + trimeperidin (n = 10); 3) paracetamol + trimeperidin + glucocorticosteroids (GC) (through treatment of the underlying disease) (n = 10). Analgesic properties and effect of each scheme were assessed according to a rating scale of pain NRS (10 points) and VAS (100 points) studied. Additionally we evaluated the effect of nefopam and paracetamol on the functional properties of platelets and hemostasis, platelet levels while monitoring and indicators of thromboelastogram (TEG). RESULTS: Application of paracetamol + trimeperidin accompanied with effectively reducing of postoperative pain (less than 5 points on the NRS). The level of postoperative pain was lower in patients who were treated with corticosteroids within the therapy of the underlying disease before surgery and who continued to receive it in postoperative period (2-3 points NRS). Nefopam use in the perioperative period is not only inferior to the analgesic effect of paracetamol, but also causes frequent side effects. Consumption of narcotic analgesic--trimeperidin when applying nefopam averaged 43 mg/day, the appointment of paracetamol--28 mg/day, using a combination of paracetamol + GC--20 mg/day. Thus, GC within the underlying disease treatment substantially reduces the need for opioid analgesics. A monitoring of the number of platelets and TEG did not shows negative effect of paracetamol and nefopam on platelet and plasma hemostasis. CONCLUSIONS: Nefopam and paracetamol may be used in patients with thrombocytopenia, as do not affect the hemostasis and platelet count. Application of postoperative analgesia scheme paracetamol + trimeperidin in patients receiving corticosteroids provides the maximum reduction of pain with the least consumption of narcotic analgesics.

[The use of central acting analgesic nefopam in postoperative analgesia in cardiac surgery patients].

A prospective, randomized, comparative study was conducted. 3 analgesia protocols were used: 1) patient controlled analgesia (PCA) with trimeperidine in combination with a nefopam constant infusion; 2) PCA with trimeperidine in combination with a nefopam bolus; 3) PCA with trimeperidine separately during early postoperative period in cardiac surgery patients. The study included 60 patients agedf rom 40 to 65 years of age (20 patients in each group). The analgesia efficacy was evaluated with a 5-point verbal rating scale (VRS) for pain intensity and inspiratory lung capacity (ILC), measured with incentive spirometer. The safety of nefopam during early postoperative period in cardiac surgery patients was shown. The combination of nefopam and trimeperidine led to a more pronounced analgetic effect. Trimeperidine consumption was significantly lower in nefopam groups than in the group of isolated PCA. Wholly adverse effects were associated with trimeperidine and were dose-related The incidence of nausea, vomiting, dizziness, weakness, bowel paresis was significantly higher in isolated PCA group than in the other two groups.

[Phenotyping by total oxidative hepatic capacity in patients undergoing laparoscopic cholecystectomy: two categories of patients and duration of post-anesthesia rehabilitation].

In patients, undergoing laparoscopy cholecystectomy, two phenotype categories were identified on the basis of the total oxidative hepatic capacity determined by antipyrine test, which differed by duration of post-anesthesia rehabilitation. The potential of antipyrine phenotyping for individualisation of anesthetics' dosing is discussed.

[Caudal-epidural injection of adjuvants and local anaesthetics in the newborns undergoing surgery].

In 45 newborns, operated on for the inborn failures of gut, the markers of stress and indices of central hemodynamics were studied up. General anaesthesia was applied together with caudal-epidural injection of local anaesthetics in 15 newborns, in 15--the adjuvants--klophelline and promedol--were added to local anaesthetics, in 15--a standard atharalgesia was used. The best and most durable effect was noted while application of anesthesia in combination with adjuvants.

[Dexmedetomidine use for postoperative adrenergic analgesia and sedation in abdominal surgery].

Comparative study of postoperative analgesia and sedation with trimeperidine and dexmedetomidine and their effects on haemodynamics and vegetative nervous system was performed. Assessment of analgesia and sedation during vagotonia (first part of the study) and hypokinetic type of haemodynamics (second part of the study) was carried out with visual analogue scale (VAS) and Richmond scale. Results of the study showed that dexmedetomidine is more effective and safer than trimeperidine for analgesia and sedation in patients with spontaneous breathing after abdominal surgery. Dexmedetomidine use allows keeping optimal type of haemodynamics and vegetative nervous system parameters on first day of postoperative period.

[Ketoprophen and nefopam combination for postoperative analgesia with minimal use of narcotic analgesics in cardio-surgical patients].

4 combinations of analgesia were studied: 1) Nefopam and patient-controlled analgesia (PCA) with Trimeperidine; 2) Ketoprofen (100 microg each 12 hours intramuscular) and PCA with Trimeperidine; 3) Nefopam, Ketoprofen and PCA with Trimeperidine; 4) PCA with Trimeperidine as monotherapy in early postoperative period in cardio-surgical patients. 80 patients (age from 40 to 70) were divided into 4 groups, 20 patients in each group. Administration of Nefopam and Ketoprofen before extubation reduced the intensity of pain syndrome (in average on 90%) and promoted the early stirring up of patients. Combination of Nefopam and Ketoprofen provided the most expressed analgesic and opioids-saving effects. In this group average amount of Trimeperidine per 24 hours was 14.7 microg that was 4.9 times less than in group of PCA with Trimeperidine as monotherapy. Dynamics of maximal inspiratory capacity of the lungs in the first three groups was better than in group of PCA with Trimeperidine as monotherapy beginning from 6th hour of study. In common undesirable effects was connected with Trimeperidine administration and depended on its dose. The frequency of nausea, vomit, dizziness and weakness was authentically higher in the group of PCA with Trimeperidine as monotherapy than in other groups.

[Opiates do not guarantee an adequate analgesia after large-volume open operations on the abdominal cavity organs].

Efficacy of systemic application of opiates (promedol) for the pain relief after big open abdominal operations, using visual-analogue scale (VAS), was estimated in 50 patients. During 36-48 h postoperatively analgesia was inadequate (VAS in a rest state more than 3 points and while movement--more than 4 points). Intensive pain (VAS 6 points and more) was noted in 58% of patients, while they are moving, and in 26%--in a rest state. Inadequate anesthesia may constitute one of causes of excessive systemic inflammatory reaction development in patients postoperatively.

[Postoperative analgesia of newborns using local anesthetic administered through wound irrigation catheter of permanent action].

The analysis of publications is devoted to the application of skin conductance monitoring in anesthesiology and intensive care. Rates of skin conductance (baseline values, the amplitude and frequency of the waves) are closely linked with the state of the sympathic nervous system. According to their dynamics it is possible to judge on the pain and stress in patients with whom the contact is difficult: newborns, infants, patients of all age groups during general anesthesia and in critical condition. According to published data monitoring skin conductance showed itself as a sensitive and promising method to identify and determine the severity of pain in all age groups, approaching by its characteristics the theses of the pain assessment perfect tool.

[Analysis of patients control analgesia with trimeperidine and ketoprofen for postoperative pain management in patients who underwent cardiac surgery].

The aim of the study is to discover adequate method of early postoperative period pain management in patients after cardiac surgery. In prospective randomized competitive study were analyzed three algorithms of analgesia: first patients controlled analgesia (PCA) with trimeperidine and (NSAID) ketoprofen, second PCA with only trimeperidine and third is ketoprofen combined with intramuscular injection of trimeperidine. There were 75 pations studied at the age of 40 to 65. The pain level was assessed according to verbal 5 points scale, inspiration lung capacity which was measured by incentive spirometry. It was shown that NSAID were safe to use in early postoperative period in patients after cardiac surgery. Combination of ketoprofen and trimeperiden showed best results in pain management. Consumption dose of trimeperidine was smaller in first group but larger than in third group where this drug was introduced fractional. All side effects were associated with trimeperedine and were depended on a dose. Patients of second group had nausea, vomiting, dizziness, weakness, enteroparesis considerably often comparing to patients of other groups, moreover rate of enteroparesis was minimal in the third group.

[Comparison of analgesics using two devices for the patient-controlled analgesia].

INTRODUCTION: A pilot unicenter blind placebo-controlled study comparing different analgesics was conducted in parallel groups, by concurrently using two patient-controlled analgesia (PCA) apparatuses in one patient, was conducted Subjects and methods. The study included patients after laparotomy. Group I patients (n=22) were proposed 2 PCA apparati, one of which contained trimeperidine solution and the other did placebo. Group 2 patients (n=17) were proposed 2 PCA apparatuses, one of which contained trimeperidine solution and the other did lornoxycam. PCA was adjusted in the same manner in both apparati. The patients were asked to determine which analgesic is best in providing 24-hour analgesia. RESULTS: There were no differences in the intensity of pain between the groups. The latter did not differ in the number of adverse reactions. Comparison showed no significant differences in the use of trimeperidine between Groups 1 and 2 patients. Among Group 1 patients, 61% considered trimeperidine as the best analgesic and 22% did placebo; 17% called none. Group 2 patients chose trimeperidine in 41% of cases and lornoxycam in 41%, none was called in 18%. CONCLUSION: Comparative assessment of analgesics, by employing 2 PCA apparatuses in one patient, allows evaluation of the efficacy of analgesics added to the conventional methods.

[Impact of preemptive analgesia on postoperative pain syndrome in laparoscopic surgery].

The study included 90 patients who had undergone laparoscopic cholecystectomy. The patients were divided into 3 groups: 1) paracetamol was given for preemptive and postoperative analgesia; 2) ketorolac tromethamine; and 3) promedol (a control group). The visual analogue scale (VAS) and the determination of the time course of changes in the blood levels of tumor necrosis factor-alpha (TNF-alpha), C-reactive protein (CRP), and glucose were used to evaluate the degree of pain syndrome. Preemptive analgesia in laparoscopic surgery using ketorolac and paracetamol could reduce the degree of postoperative pain syndrome by 40.1%, as shown by the VAS. Comparative analysis of the characteristics of the agents showed that paracetamol produced a more powerful antistress defense, as confirmed by the time course of changes in the levels of TNF-alpha and CRP.

[Analgesic and opioid-sparing effects of intravenous paracetamol in the early period after aortocoronary bypass surgery].

The study was to evaluate the analgesic and opioid-sparing effect of intravenous paracetamol injections in cardiosurgical patients in the early postoperative period. Adequate analgesia within the first 12-18 hours of the early postoperative period is very important for a good prognosis of the further course of pain syndrome and for the reduction of a risk for its progression to its chronic form. In early studies, propacetamol lowered morphine use after orthopedic and gynecological operations. The efficacy of paracetamol used in cardiac surgery has been little studied and the results of the studies are conflicting. The randomized, blind, placebo-controlled study included patients after aortocoronary bypass surgery, of them 22 patients received paracetamol and 23 had placebo. The test drug (perfalgan 100 ml or placebo) was intravenously injected 30 min before extubation and then every 6 hours within succeeding 18 hours. The intensity of the pain syndrome was rated by a 5-score verbal scale every 2 hours. With pain score of 2 or more, promedol was intramuscularly administered in a dose of 10 mg. Inspiratory volume was recorded before extubation and the first administration of a drug just after extubation and then every 2 hours. The baseline indices did not differ in both groups. Throughout the observation, the inspiratory volume was lower in the paracetamol group than in the placebo group; however, there was a statistically significant difference (p = 0.012) in the reduction in the manifestations of the pain syndrome (by 81%) only just after tracheal extubation. During this period, inspiratory volume values were higher in the paracetamol group; however, a statistically significant (39%) difference between the groups in the mean values was obtained only during and 2 hours after extubation. In the perfalgan group, the mean total use of promedol was 36% less than in the placebo-group, which was statistically significant (p = 0.019). The early postoperative use of paracetamol after myocardial revascularization reduces the intake of opioids and diminishes the intensity of the pain syndrome within the first hours after extubation, which promotes a higher thoracic excursion, as confirmed by a statistically significant increase in the maximum inspiratory capacity.

[Efficacy and safety of lornoxicam in an early postoperative period].

AIM: To compare quality of anesthesia with opioid drug and nonsteroid anti-inflammatory drugs in 123 patients after extensive operative interventions of the lungs and trachea, abdominal organs, lower limbs. MATERIAL AND METHODS: Patients of group 1 took lornoxicam for relief of postoperative pain syndrome, those of group 2--promedol. Quality of anesthesia was assessed by visual-analogue and verbal scales, day dose of analgetic drug, administration of promedol, side effects incidence. RESULTS: Lornoxicam in a dose 8 mg intravenously has comparable with 20 mg promedol analgetic effect. This justifies its use as a basic analgetic for treatment of acute pain after extensive surgery. Lornoxicam allows surgeons to do without opioids in 10-45% patients or to reduce their dose by 32-65%. CONCLUSION: Adequate anesthesia with lornoxicam and promedol early after surgery on the chest and abdominal organs, major vessels of the lower limbs occurs in 82 and 87% patients, respectively. Lornoxicam administration as continuous intravenous infusion and controlled analgesia in older patients eliminates the need in opioid analgetics in 45% cases and is well tolerated.

[Current approaches to the analgesia of spontaneous child birth].

The authors have compared various modes of spontaneous labor. Prolonged epidural infusion of naropine in combination with fentanyl has been found to cause a less motor block and therefore it may be used in the late first-to-second period of labor. Adequate analgesia ensures a smooth course of the second labor period and promotes the reduction in its duration and the correction of central hemodynamic and hormonal homeostastic disorders. The administration of moradol provides adequate analgesia of the first labor period, prevention, and elimination of abnormal labor activity, without exerting a depressive effect on maternal and neonatal respiration, which makes it possible to consider this procedure as an alternative mode of labor pain relief if there are contraindications to epidural analgesia.