Wound analgesia in a patient with hemophilia in a highly traumatic operation.

AIM: The aim of the study was to describe the use of the wound analgesia method in a patient with hemophilia in the case of a clinical case. MATERIALS AND METHODS: A patient with severe hemophilia A underwent postoperative analgesia after total knee replacement (within the first 48 hours) with an extended infusion of local anesthetic (ropivacaine) into the wound. RESULTS: During the first 8 hours, the patient received 20 mg of morphine (with the aid of a device for patient-controlled analgesia), the pain level ranged from 7 to 4 points. Further, there was a sufficient effect (NRS - 2 points), from anesthesia only with ropivacaine, using a system for anesthetizing surgical wounds. Complications and side effects were not noted. CONCLUSION: The clinical case demonstrates an effective and safe method of prolonged analgesia in patients with hemophilia. Considering encouraging data, further study of wound analgesia in this category of patients is necessary.

[The specific features of pain syndrome in patients with hemophilia]. / Osobennosti bolevogo sindroma u patsientov s gemofiliei.

AIM: to study the nature of pain in hemophilic arthropathy and its prevention ways used by patients with hemophilia. SUBJECTS AND METHODS: A prospective, multicenter, cross-sectional study was conducted to interview 136 patients with hemophilia A or B. The survey included 32 points, including questions about drug and nondrug pain treatment, as well as questionnaires to assess the severity of pain and its impact on daily life (Brief Pain Inventory) and those to identify a neuropathic pain component (PainDetect questionnaire). RESULTS: 83 (75%) patients with hemophilia experienced acute pain associated with bleeding into the large joints; 44 (39%) patients had chronic pain that had lasted longer than six months; 33% assessed the moderate pain experienced in the past 24 hours as severe (more than 5-8 of the 10 scores). In addition to the above, only 32% of the respondents indicated that they had painless intervals within the last 24 hours. 75% of the hemophilia patients mentioned to have limited daily activities. 74% reported their partial or complete disability when pain occurred. 77% of the respondents pointed out that when having pain, they had experienced great difficulty walking. 55% of the hemophilia patients had sleep disorders because of pain. When acute pain occurred, only 91 (81%) respondents injected a factor VIII or IX preparation, 37% of the respondents used narcotic analgesics; 51% received different nonsteroidal anti-inflammatory drugs; 13% took paracetamol. Some patients indicated that they used alcohol and illegal narcotic drugs to relieve pain. Attention is drawn to the fact that the hemophilia patients very frequently took painkillers: 60% of the respondents used analgesics every month; of them 49% had them every week, 11% every day. Most patients (n=83 (74%)) stated that they treated pain (prescribed drugs) themselves; 49 (44%) patients held they were dissatisfied with their pain treatment. When the question as to how the analgesic you used could "remove' pain was asked, only 12 (10%) patients answered that this could fully relieve the pain; 31 (26%) patients told that the pain was not reduced even by half. The study has shown that a neuropathic pain component is very common in hemophilia patients (31%). CONCLUSION: Pain in patients with hemophilia is a serious problem that negatively affects their quality of life, including their working capacity. The prevention and treatment of pain in hemophilia patients should involve the following: organization of educational activities and pain services; adequate treatment of acute pain; detection and prevention of a neuropathic pain component.

[Pain treatment in patients with hemophilia].

Pain in patients with hemophilia is an urgent problem. The possibilities of using analgesic drugs are interesting by virtue of the specific features of pain syndrome and the problems of treatment in these patients. Foreign and Russian trials using current analgesics are analyzed; difficulties in choosing analgesic therapy and in performing anesthesia mode in patients with congenital hypocoagulation and hyperalgesia are discussed.

[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.