Assessment of postoperative pain: impact of clinical experience and professional role

Background: Unrelieved postoperative pain is still reported to be a rather common clinical problem which may be related to inadequate routines for pain assessment. Therefore, the aim of the study was to describe strategies used by experienced and less experienced nurses and physicians in their assessment of postoperative pain and to relate different approaches, clinical experience, and professional role to the accuracy of the pain ratings.
Methods: Data collection was based on repeated interviews with nurses (n=30) and physicians (n=30) in connection with clinical pain assessments (n=180) including VASscoring
Results: Commonly used strategies in the pain assessment were: - how the patient looks, - what the patient says, - the manner of talking, and - past experience of similar circumstances. The mean VAS-score given by the patients (6.1±21.1) was significantly (P<0.001) higher than that rated by the staff members (4.9±21.2). Nurses as well as physicians overestimated low and underestimated high levels of pain indicated by the patients. The accuracy of the ratings by nurses, especially by more experienced ones (≤10 years in nursing), was found to be less precise than that of physicians. The pain assessment of these very experienced nurses was characterized by a systematic underestimation.
Conclusions: The present study emphasizes a need for definition of more precise strategies for clinical postoperative pain assessment which better take into consideration the pain experiences and needs of individual patients     

Electrocardiographic and Clinical Predictors of Torsades de Pointes Induced by Almokalant Infusion in Patients with Chronic Atrial Fibrillation or Flutter: A Prospective Study

The aim of this study was to identify predictors of torsades de pointes (TdP) in patients with atrial fibrillation (AF) or flutter exposed to the Class III antiarrhythmic drug almokalant. TdP can be caused by drugs that prolong myocardial repolarization. One hundred patients received almokalant infusion during AF (infusion 1) and 62 of the patients during sinus rhythm (SR) on the following day (infusion 2). Thirty-two patients converted to SR. Six patients developed TdP. During AF, T wave alternans was more common prior to infusion (baseline) in patients developing TdP (50% vs 4%, P < 0.01). After 30 minutes of infusion 1, the TdP patients exhibited a longer QT interval (493 ± 114 vs 443 ± 54 ms [mean ± SD], P < 0.01), a larger precordial QT dispersion (50 ± 74 vs 27 ± 26 ms, P < 0.05), and a lower T wave amplitude (0.12 ± 0.22 vs 0.24 ± 0.16 mV. P < 0.01). After 30 minutes of infusion 2, they exhibited a longer QT interval (672 ± 26 vs 489 ± 74 ms, P < 0.001), a larger QT dispersion in precordial (82 ± 7 vs 54 ± 52 ms, P < 0.01) and extremity leads (163 ± 0 vs 40 ± 34 ms, P < 0.001), and T wave alternans was more common (100% vs 0%, P < 0.001). Risk factors for development of TdP were at baseline: female gender, ventricular extrasystoles, and treatment with diuretics; and, after 30 minutes of infusion: sequential bilateral bundle branch block, ventricular extrasystoles in bigeminy, and a biphasic T wave. Patients developing TdP exhibited early during almokalant infusion a pronounced QT prolongation, increased QT dispersion, and marked morphological T wave changes.     

Surface-related triggering of the neutrophil respiratory burst. Characterization of the response induced by IgG adsorbed to hydrophilic and hydrophobic glass surfaces

Hydrophilic and hydrophobic glass surfaces precoated with human albumin, fibrinogen, or IgG were investigated with respect to their ability to activate the neutrophil NADPH-oxidase. We found that IgG-coated surfaces induced a substantial and prolonged neutrophil production of reactive oxygen species (ROS). When a hydrophilic surface was used to support protein binding, a somewhat lower neutrophil response (around 35%) was obtained, compared with the response induced by IgG on a hydrophobic surface. The production of ROS was completely eliminated when cytochalasin B was added to the measuring system, suggesting the involvement of the cell cytoskeleton in the activation process. The relation between the intra- and extracellular generation of ROS was further assessed, and we found that most of the ROS produced were released from the cells, in agreement with a model in which the activating surfaces induce a ‘frustrated’ phagocytic response. Serum totally inhibited ‘frustrated’ phagocytosis provided that the IgG molecules were sticking to a hydrophilic surface.     

Left ventricular ejection fraction, end–diastolic volume and endsystolic volume during induction of anaesthesia

Abstract: Left ventricular ejection fraction, end–diastolic volume and end–systolic volume were determined in 74 patients with ischaemic heart disease (IHD), during induction of anaesthesia, using different anaesthetic techniques. Ejection fraction measured with nuclear angiocardiography (Nuclear Stethoscope), was combined with stroke volume, determined with thermodi–lution, to calculate end–diastolic volume and end–systolic volume. Together with pressure measurements, the left ventricular pressure–volume relationship in end–distole and end–systole could be evaluated. Left ventricular diameter, determined with transthoracic 2D echocardiography, was subsequently studied during induction of anaesthesia in 11 patients with IHD. The results from this study were compared with the findings of previous studies. In a further study the relationship between pressure readings in the ascending aorta and the radial artery was investigated during anaesthesia in 26 patients with IHD. Special reference was made to the relationship between aortic and radial artery dicrotic notch pressure. Conclusions: 1. Induction of anaesthesia with hypnotics, low dose fentanyl and pancuronium caused a considerable decrease in left ventricular preload, estimated as end–diastolic volume (I, III, V). 2. Induction of anaesthesia with isoflurane and nitrous oxide in combination with hypnotics, low dose fentanyl and pancuronium, caused a similar reduction in preload (II). 3. The decrease in preload, during induction of anaesthesia with the low dose fentanyl techniques, was of the same magnitude (31–45%), despite the use of several different drug combinations (I, II, III, V). 4. In addition to the decrease in end–diastolic volume, there was a decrease in end–systolic volume during induction of anaesthesia in the low dose fentanyl groups. The net result was an increase in ejection fraction and a decrease in stroke volume (I, II, III). 5. Laryngoscopy and intubation caused a decrease in left ventricular ejection fraction and an increase in end–diastolic and end–systolic volume in the low dose fentanyl groups (I, II, III). 6. Nitroglycerin as an iv bolus effectively prevented the decrease in ejection fraction and the increase in end–diastolic and end–systolic volume during laryngoscopy and intubation, during induction of anaesthesia with a low dose fentanyl technique (III). 7. Left ventricular filling pressure was poorly correlated to left ventricular enddiastolic volume (I, II, III). 8. A high dose fentanyl technique in combination with pancuronium implied stable haemodynamics, with reference to left ventricular ejection fraction, enddiastolic volume and end–systolic volume, during induction of anaesthesia including laryngoscopy and intubation (I). 9. Left ventricular end–systolic pressure, measured as the dicrotic notch pressure in the ascending aorta, could be estimated from pressure measurements in the radial artery, with reasonable accuracy, in the period immediatley preceding cardio–pulmonary bypass (IV). 10. The estimated changes in left ventricular end–diastolic and end–systolic volume, during induction of anaesthesia, were similar using two different techniques of measurement: therrnodilution in combination with nuclear angiocardiography (I, II, III) and transthoracic echocardiography (V).     

The effect of indomethacin on cerebral blood flow and oxygen consumption in the rat at normal and increased carbon dioxide tensions

The effect of the fatty acid cyclo-oxygenase inhibitor indomethacin on cerebral blood flow (CBF) and the metabolic rate for oxygen (CMRO₂) was studied in paralyzed and artificially ventilated rats. In normocapnic animals, the drug (10 mg·kg^-1i. v.) reduced CBF to 50% of control without a measurable effect on CMRO₂. During hypercapnia (Pa_CO2 70–80 mmHg) the increase in CBF was reduced by about 80% but CMRO₂ remained unchanged. Autoradiographic evaluation of local CBF in 20 brain structures indicated that the reduction in CBF was relatively uniform throughout the brain. Dose response curves showed that an effect on CBF was evident already at an indomethacin dose of 1 mg·kg^-1 and maximal effects were obtained with 3–5 mg·kg^-1. Following i. v. injection of the drug reduction in CBF was observed already after 10 s and the full response occurred after 1–2 min. It is concluded that metabolites of arachidonic acid, possibly mainly prostacyclin, are powerful modulators of normal cerebrovascular tone, and help to mediate the CBF response to increased CO₂ tensions. However, since indomethacin does not modify the circulatory response in other conditions with increased CBF these substances do not qualify as general coupling factors controlling CBF in physiological or pathological states.     

Measurement of Ventilation and Respiratory Mechanics during Continuous Positive Airway Pressure (CPAP) Treatment in Infants

ABSTRACT. A new method has been evaluated for measuring ventilation and lung mechanics in spontaneously breathing infants by means of a face chamber. Airway flow is measured with a pneumotachograph inserted between the face chamber and a stable pressure source. Oesophageal pressure is measured via a water-filled oesophageal catheter. The method is suitable for use in conjunction with continuous positive airway pressure (CPAP) treatment in neonatal intensive care. A flat frequency response curve up to 15 Hz for the two measuring systems (i.e., airway flow and oesophageal pressure), and a time shift between the two respective signals of less than 2 msec are prerequisites for correct evaluation of respiratory mechanics. In preterm infants with chest distortion, the inhomogeneity of pleural pressure affects the significance of resistance and compliance values, as calculated from oesophageal pressure. Supra-diaphragmatic pressure variations reflect the resistive and elastic load on the diaphragm exerted by the lungs and thorax. Thus, oesophageal pressure is still useful in studies of respiratory mechanics in preterm infants.     

Mechanisms of Pancreatic B-Cell Degeneration during the Course of Insulin-dependent Diabetes Mellitus

ABSTRACT. This paper presents a review of different mechanisms possibly responsible for the degeneration of the pancreatic B-cell in insulin-dependent diabetes mellitus. The genetic dependence probably located in the HLA DR-locus of the sixth chromosome and its role in an autoimmune reaction against antigenieally altered pancreatic B-cells is discussed. The actions of alloxan and streptozotacin in the induction of experimental diabetes, as models for postulated human B-cytotoxins, are described.     

Erythropoiesis: Correlations Between Iron Status Markers During Normal Pregnancy in Women with and without Iron Supplementation

The aim was to evaluate relationships between iron status markers (haemoglobin, erythrocyte indices, serum iron, serum transferrin, serum transferrin saturation, serum ferritin) in normal pregnancy. Iron status markers were measured at 4-week-intervals during pregnancy and postpartum in 120 healthy women; 62 had daily treatment with tablets containing 66 mg ferrous iron, 58 were treated with placebo. Placebo-treated: Ferritin displayed positive correlations with transferrin saturation during 2nd and 3rd trimester. There were positive correlations between ferritin, erythrocyte MCV and MCH during 2nd and 3rd trimester and postpartum. Prior to delivery and postpartum, ferritin demonstrated positive correlations with haemoglobin. Transferrin saturation showed positive correlations with MCV, MCH and MCHC during 2nd and 3rd trimester and postpartum. Transferrin saturation displayed positive correlations with haemoglobin prior to delivery and postpartum. Iron-treated: In general, there were no correlations between iron status markers. Positive correlations appeared postpartum between ferritin, transferrin saturation and MCHC but not with haemoglobin. Transferrin saturation showed a positive correlation with MCH postpartum, but not with haemoglobin. Conclusion: The patterns of relationships in placebo-treated women were consistent with iron deficient erythropoiesis.     

Erythropoiesis: Short Report: Translation of Analysis Results between Serum Ferritin Assays, Ferritin RIA AmershamTM and Abbott AxSYMTM Ferritin

The serum ferritin assays, Ferritin RIA Amersham(TM) and Abbott AxSYM(TM) Ferritin were compared in order to translate values from one assay to the other. Serum ferritin was analysed with both assays in 102 samples. Logarithmic transformation of the results was performed in order to stabilize the variance. The relationship between the untransformed values was most exactly expressed by a proportionality: AxSYM Ferritin = 0.873 * RIA Ferritin. Due to this proportionality, the numerical difference between the assays increases with the ferritin concentration, although the percentage difference between the assays remains constant.