Evaluation of postoperative pain therapy with patient-controlled analgesia from the viewpoint of the patient and nursing staff

Patient-controlled analgesia has been proven to be an effective technique in postoperative pain management. The aim of our study was to evaluate PCA on general surgery wards. 311 patients and their nurses were questioned about their experiences in using PCA for postoperative pain management. Satisfaction with pain relief judged by both patients and nursing staff, incidence of negative side effects and technical problems were studied. The great majority of patients and nursing staff rated the quality of pain relief as being satisfactory. Incidence of negative side effects was extraordinarily low. There was no respiratory depression observed, technical problems hardly arose. Most of the patients coped very well with operating their PCA-pumps. We conclude that PCA is a safe and effective method in postoperative pain management on surgical wards. Under the condition of regular monitoring of pain intensity, of analgesic consumption, level of sedation and of side effects by trained medical and nursing staff, monitoring of respiration and vigilance is not necessary for the PCA regimen we used.     

Die Serumproteinbindung von Fentanyl

Numerous basic drugs are extensively bound to α₁-acid glycoprotein. Fentanyl, with a pK_a value of 8.43, is also a basic drug. Protein binding studies have yielded contradictory results concerning binding of fentanyl to α₁-acid glycoprotein. In this study we investigated time courses of serum protein concentrations and serum protein binding of fentanyl during postoperative acute phase reaction, assuming that an increase of α₁-acid glycoprotein is accompanied by an increase of serum protein binding, if fentanyl is extensively bound to α₁-acid glycoprotein. Fentanyl protein binding measurements using equilibrium dialysis can be affected by volume shifts and pH changes. Therefore, volume shifts from buffer to serum and the influence of various phosphate buffers on increasing pH due to loss of CO₂ were also evaluated. Methods. Thirteen patients with no history of renal or hepatic disease undergoing an operation with a significant acute phase reaction were studied. Preoperatively and on the first 3 postoperative days serum concentrations of α₁-acid glycoprotein, albumin, total protein and apolipoprotein A and B were determined by rocket immunoeolectrophoresis, biuret method and laser nephelometry, respectively. Corresponding serum protein binding of fentanyl was measured by adding 40?ng of fentanyl to 1?ml serum followed by equilibrium dialysis at 37°?C for 4?h. A 0.167?M phosphate buffer (pH?7.27), which gave a final pH of 7.40, was used. Volume shifts from buffer to serum were measured. Fentanyl concentration in serum before dialysis (F_S) was determined by gas chromatography, and fentanyl concentration in buffer after dialysis (F_B) was determined by radioimmunoassay. Serum protein binding (SPB) was calculated by the formula: where c is a correction factor. Ten randomly selected patient sera were dialyzed against four phosphate buffers of different pH values and molarities, and the serum pH at the end of equilibrium dialysis was measured. Results. Postoperatively, the serum concentration of α₁-acid glycoprotein rose to 151% of the control value. In contrast, serum protein binding of fentanyl did not change significantly, with a slight decrease to 96% of control value. There was a significant decrease in serum concentrations of albumin (3rd postoperative day), total protein (2nd postoperative day) and apolipoprotein B (1st–3rd postoperative day) to 85%, 90% and 75% of control values, respectively. Changes in apolipoprotein A concentration were not significant. Protein binding of fentanyl did not correlate with α₁-acid glycoprotein and apolipoprotein A, but there was a positive linear relationship between protein binding of fentanyl and albumin, total protein and apolipoprotein B. At the end of equilibrium dialysis the mean volumes of the serum and buffer compartments were 1114±72 and 834±68?μl, respectively. The two phosphate buffers, with pH?7.30 (0.15?M) and pH?7.27 (0.167?M), gave final serum pH of 7.42 and 7.40, respectively. Conclusions. Present findings suggest that in contrast to other basic drugs, fentanyl binding to α₁-acid glycoprotein is of minor importance. In agreement with the findings of former studies, protein binding of fentanyl depended on albumin, total protein and apolipoprotein B concentrations. Due to unspecific binding of fentanyl by hydrophobic interactions, a major role of albumin, which amounts to about 60% of total protein, seems to be evident. Determining fentanyl protein binding by equilibrium dialysis, volume shifts must be taken into account if calculation is based on fentanyl concentrations in plasma (serum) and buffer after dialysis, and an appropriate buffer must be used.     

Effects of Extracorporeal Shock Wave Lithotripsy on Plasma Concentrations of Endothelin and Renin in Humans

Purpose

There is ongoing controversy regarding blood pressure changes after extracorporeal shock wave lithotripsy (ESWL*). Experimental data suggest a role for renin but only few data are relevant to humans. It has been shown that renin secretion is stimulated by endothelin, a recently discovered peptide with strong vasoconstrictive properties and stimulating effects on renin secretion. Endothelin is relevant in the development of hypertension and acute renal failure.*Dornier Medical Systems, Inc., Marietta, Georgia.

Materials and Methods

In a prospective study of 48 normotensive patients undergoing ESWL for renal stones the influence of high energy shock waves on plasma endothelin and active renin was analyzed. These substances are secreted by renal cells in response to hemodynamic alterations, and inflammatory and traumatic processes. Peripheral blood samples were analyzed for active renin and endothelin before, and immediately, 1, 3 and 5 days after ESWL. Blood pressure was measured before, and 1, 3 and 5 days after ESWL.

Results

Only a slight and transient increase was noted in active renin, which was in the same range as that found after mental stress. Endothelin and blood pressure were not significantly influenced by ESWL. There was no correlation between endothelin and active renin. Thus, the increase in active renin was not mediated by endothelin.

Conclusions

The transient increase in active renin cannot be attributed to the development of hypertension. The lack of influence of ESWL on endothelin indicates that ESWL, at least in the routine clinical setting, does not cause severe renal trauma.     

Dopamine,dopexamine and dobutamine in liver transplant recipients: a comparison of their effects on hemodynamics,oxygen transport and hepatic venous oxygen saturation

The purpose of this study was to determine the effects of vasoactive treatment with dopamine (DO), dopexamine (DX), and dobutamine (DOB) on hemodynamics, oxygen transport and hepatic venous oxygen saturation (SvhO₂) after orthotopic liver transplantation (OLT). A pulmonary artery catheter was inserted into the right hepatic vein of 17 OLT patients. Timed infusion of DO, DX, and DOB was performed at the following rates: DO at 4 and 8 g/kg per minute, and DOB at 5 and 10 g/kg per minute. Hemodynamics, oxygen transport variables, and SvhO₂ were assessed. Each catecholamine induced a significant increase in cardiac index, oxygen delivery, and SvhO₂. Mean arterial pressure was increased during DO and DOB, but significantly reduced during DX. Each inotrope increased oxygen delivery in parallel with SvhO₂, suggesting a corresponding increase in hepatic oxygen supply. Therefore, it appears that each vasoactive drug may be utilized in OLT patients to provide oxgen delivery without impairment of splanchnic oxygenation.     

Anesthesiologic problems and specifics in the management of severe pelvic injuries]

There is a close relationship between trauma of the pelvis, hemorrhagic shock, microcirculation disturbances and multiple organ failure. Of primary importance are the treatment of pain, early intubation, artificial ventilation, protection against heat loss and replacement of massive blood loss. Contrary to conventional volume replacement by electrolyte solutions, the author favors the administration of colloids, especially the new concept of "small volume resuscitation," i.e., the rapid infusion of a mixture of hypertonic saline solution and hyperoncotic dextran. Although there are limitations, the central venous and pulmonary arterial pressure reflect the volume balance of the circulation. The oxygen partial pressure of mixed venous blood, more or less reflecting the global oxygen supply state of the organism, can be measured only by means of a pulmonary artery catheter. The outcome depends greatly on optimization of the oxygen supply to a patient in shock whose oxygen needs are remarkably increased. Therapy should be aimed at keeping the arterial oxygen tension above 150 mmHg, increasing the cardiac index to 50% above normal, and stabilizing the hemoglobin concentration at an individually optimized value.     

Familiale Beziehungsmuster und Patientenkarriere männlicher schizophrener Kranker

Zusammenfassung Mit Hilfe eines Persönlichkeitsfragebogens (Gießen-Test), der von beiden Eltern und dem schizophrenen Kranken bei dessen Entlassung aus der ersten stationären psychiatrischen Behandlung ausgefüllt worden war, wurde die Personenwahrnehmung und damit mittelbar die Beziehung in der Familie untersucht. Über alle drei Selbstbilder und sechs Fremdbilder von insgesamt 28 Familien mit einem schizophrenen Sohn sowie von 29 als Vergleichsgruppe dienenden Familien mit einem chirurgisch kranken Sohn wurde eine Clusteranalyse berechnet, die die Abgrenzung von fünf Clustern erlaubte, von denen zwei vor allem durch Familien mit Schizophrenen und zwei vor allem durch solche mit organisch kranken Söhnen gebildet wurden; ein Cluster war unspezifisch. Ein 2-Jahres-follow-up ergab, daß 13 schizophrene Kranke erneut die Klinik aufsuchen mußten. Es fand sich keine statistisch bedeutsame Beziehung zwischen den untersuchten psychiatrischen und soziodemographischen Parametern und dem Rehospitalisierungsrisiko. Als besonders gefährdet erwiesen sich jedoch Familien, in denen sich nach den Ergebnissen der Clusteranalyse ein Konflikt zwischen Eltern und Sohn um die Definition als Kranker auf dem Hintergrund rigider Normvorstellungen abbildete. Die Übernahme der Krankenrolle durch den Patienten ging hingegen nur in der Hälfte der Fälle mit einer Rehospitalisierung einher, führte also nicht zwangsläufig zur Ausgrenzung aus dem Familienverband. Söhne aus Familien, die als besonders gesund imponierten, aber auch Söhne aus Familien mit dominanten Müttern wurden im Untersuchungszeitraum nicht erneut in die Klinik aufgenommen.

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Summary Patterns of personal relationships within the families of male schizophrenic patients, and their relationship to clinical course and outcome, were examined by means of a personality questionnaire (Gießen-Test), completed by both parents and by the schizophrenic patient himself at the time of discharge from his first psychiatric in-patient treatment. The test yields scores related to the self-perceptions of the individual and to his perceptions of the other nuclearfamily members. A cluster analysis was performed on all three self-perception scores and six scores of the perceptions the three family members had of each other, for a total of 28 families each with a schizophrenic son and for a control group of 29 families each with a surgically-ill son. This analysis allowed five clusters to be distinguished, two of which consisted predominantly of families with schizophrenic sons and two predominantly of families with surgically-ill sons. The remaining cluster comprised a mixed group. A two-year follow-up showed that 13 schizophrenic patients had been readmitted to hospital. There was no statistically significant relationship between the psychiatric and sociodemographic parameters examined and the re-hospitalization rate. Readmissions were, however, more frequent from families in which the research findings had indicated conflicting mutual perceptions of parents and sons, against a background of rigid notions of normality. Acceptance by the patient of the notion of being ill was associated with re-hospitalization in only about half of the cases, so that it had not necessarily led to rejection by the family unit. No patients were readmitted during the follow-up period from families which had represented themselves as particularly healthy, or from families with dominant mothers.

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Teil des von der Deutschen Forschungsgemeinschaft unterstützten Projektes Interaktion in Familien mit Schizophrenen     

Eight month follow-up of delinquent adolescents: predictors of short-term outcome

Clinicians working with young delinquents are concerned with finding methods to predict recidivism in these subjects. It has not been investigated yet to what extent psychiatric assessment can be of any help in this field. In this study, we investigated whether psychiatric assessment can help to predict recidivism in already delinquent adolescents. By means of semi-structured psychiatric assessment (Child Assessment Schedule), developmental interview of the parents and self-report instruments, we assessed the psychiatric status of 72 delinquent adolescents, adjudicated before the Juvenile Court of Antwerp (Belgium). A follow-up of criminal status after eight months was conducted. Self-report questionnaires by the subjects did not differentiate recidivists from non-recidivists, while parent questionnaires did. Through a semi-structured interview, we found that a diagnosis of conduct disorder significantly predicts recidivism, while subjects with ADHD and substance abuse show a tendency towards more recidivism. We were unable, however, due to the small number of subjects showing a psychiatric disorder (e. g. ADHA and PTSD) unrelated to conduct disorder, to assess the relative contribution of these disorders to the recidivism rate. This study found that psychiatric assessment of delinquent adolescents could be of help in predicting recidivism. The necessity of gathering information from parents and teachers is demonstrated. Future research should include a more extensive group of a delinquent adolescent and should focus on the effect of therapeutic interventions. Received: 29 June 1999 / Accepted: 1 February 2000     

A simple theoretical verification of monitor unit calculation for intensity modulated beams using dynamic mini-multileaf collimation.

A spreadsheet based program is presented to perform an independent Monitor Unit (MU) calculation verification for the Quality Assurance (QA) of Intensity Modulated Radiation Therapy (IMRT) using Dynamic MultiLeaf Collimation (DMLC). The computed dose value is compared to the planned dose by calculating the percent dose difference per Intensity Modulated Beam (IMB) and absolute dose difference per IMB. The proposed acceptability levels are +/-5.0% or +/-2.0 cGy for the percent dose difference per IMB and the absolute dose difference per IMB, respectively. For percent dose difference per treatment, an acceptability level of +/-2.0% is proposed. The presented program is considered adequate for checking the treatment plans calculated for IMRT treatments using DMLC as a part of the QA procedure.