Correction to: S(+)-ketamine : Current trends in emergency and intensive caremedicine.

Correction to: Wien Klin Wochenschr 2017 https://doi.org/10.1007/s00508-017-1299-3 The article S(+)-ketamine Current trends in emergency and intensive caremedicine, written by Helmut Trimmel, Raimund Helbok, Thomas Staudinger, Wolfgang Jaksch, Brigitte Messerer, Herbert Schöchl and Rudolf Likar, was ….

[Pain relief during and after surgical procedures : Results of an Austria-wide patient survey on postoperative pain and perioperative pain management]. / Schmerzversorgung bei chirurgischen Eingriffen : Ergebnisse einer österreichweiten Patientenbefragung zur postoperativen Schmerzsituation und zum perioperativen Schmerzmanagement.

BACKGROUND: Pain after surgery, especially on the first postoperative day, results in longer hospital stays, increased complication rates and may also cause a higher risk of pain chronification. However, the expected intensity of pain is often misjudged and therefore not adequately treated. METHODOLOGY: An Austria-wide patient survey on the pain situation on the first postoperative day and on the quality of perioperative pain management was carried out on a voluntary and anonymous basis. RESULTS: Regarding the intensity of pain a clear gender difference could be observed. Women were more prone to more severe pain than men across all age groups. This difference was most pronounced in the younger age groups (18-40 years) and in those patients showing the highest pain scores. Treatment satisfaction was correlated (high significance) with pain intensity on exercise (p < 0.01), maximum pain (p < 0.01), least pain (<0.01) and frequency of postoperative pain assessment. DISCUSSION: The risk of postoperative pain can be reduced by optimal care structures. Since patients treated in optimal care structures had significantly lower pain scores on exercise and with respect to maximum pain, the investment in the optimization of such resources should be carefully planned. Special attention should be paid to postoperative pain management in women, especially in younger female patients.

[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

[Pain in hospital: Assessing the pain situation in Austrian patients]. / Schmerz im Krankenhaus: Erfassung der Schmerzsituation österreichischer Patienten.

BACKGROUND: In a survey of all adult inpatients at the Wilhelminen Hospital in Vienna and the Klagenfurt Clinic on Lake Wörthersee, data on pain prevalence, the most frequent sites of pain, pain intensity, pain type, effect of pain on patients, pain evaluation on the various wards, pain precipitating factors, and patient satisfaction were collected. MATERIALS AND METHODS: All inpatients > 18 years were questioned using a questionnaire developed by the investigators at the Department for Anesthesia, Intensive Care, and Pain Medicine at the Wilhelminen Hospital. RESULTS: A pain prevalence of 45.7% was found at the Wilhelminen Hospital and of 40.8% at the Klagenfurt Clinic. Women reported pain significantly more often than men. No significant difference was found between surgical and conservative treatment wards in terms of pain prevalence. Patients on conservative treatment wards reported significantly higher current pain intensity than those in surgical departments. The most common areas of pain were joints and bones. A score >3 in the ID pain questionnaire was reached by 8.8% (Wilhelminen Hospital) and 4.0% (Klagenfurt Clinic) of participants. Pain influenced mood, mobility, and nighttime sleep, and was intensified by the daily clinical routine. CONCLUSION: Overall, it was demonstrated that the majority of patients at both hospitals were satisfied with the pain management. However, pain management in conservative treatment disciplines must not be neglected. More intense current pain, a worse quality of life, and a trend toward lower patient satisfaction indicate that analgesic treatment in nonsurgical disciplines should be optimized.

[Austrian interdisciplinary recommendations on pediatric perioperative pain management: background, aims, methods and key messages]. / Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern : Hintergrund, Ziel, Methodik und Kernaussagen.

These recommendations were originally commissioned by the"Österreichische Gesellschaft für Anästhesiologie, Reanimation und Intensivmedizin" (ÖGARI, Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine). Against this background, Austrian experts from the disciplines anesthesiology, pain management, pediatrics and the "Berufsverband Kinderkrankenpflege" (Professional Association of Pediatric Nursing) have with legal support developed evidence-based and consensus recommendations for the clinical practice. The recommendations include key messages which cover the most important recommendations for the individual topics. The complete recommendations on pediatric perioperative pain management consist of seven separate articles which each deal with special sub-topics with comments on and explanations of the key messages. The target groups of the recommendations are all medical personnel of the individual disciplines involved in the treatment of perioperative and posttraumatic pain for neonates, infants and children up to 18 years old.

[Pharmacodynamic and pharmacokinetic characteristics of pain therapy in neonates: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Pharmakodynamische und pharmakokinetische Besonderheiten der Schmerztherapie bei Neugeborenen : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

The false assumption that neonates are less sensitive to pain than adults led to a long delay in the introduction of a reasonable pain therapy for children. Even if the basic principles of the development, transmission and perception of pain in premature infants and neonates are not completely understood, the results of studies have clearly shown that pain can be perceived from 22 weeks of gestation onwards. This knowledge results in the necessity to also administer an adequate pain therapy to premature and newly born infants. However, for the use of pharmaceuticals in neonates and infants the pharmacodynamic and pharmacokinetic characteristics must also be considered. The immaturity of the organs liver and kidneys limits the metabolism and also excretion processes. The different physical proportions also modify the dosing of pharmaceuticals. Children in the first year of life differ substantially from adults in physiology, pharmacodynamics and pharmacokinetics. The care of neonates and infants requires specialist knowledge which is described in this article.

[Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. / Perioperative systemische Schmerztherapie bei Kindern : Österreichische interdisziplinäre Handlungsempfehlungen zum perioperativen Schmerzmanagement bei Kindern.

BACKGROUND: Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS: The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS: In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE: Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.

The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study.

BACKGROUND: Mesh reinforcement has become the standard of care in the open and laparoscopic repair of inguinal hernia. Chronic pain after inguinal hernia repair is often due to nerve injury by penetrating mesh fixation devices such as staples (ST), tacks, or sutures. In several studies on hernioplasty, atraumatic mesh fixation with fibrin sealant (FS) proved to be efficient in terms of fixation strength and elasticity. Unfortunately, most of these studies did not provide a standardized follow-up and assessment of the development of chronic pain (CP) and the quality of life (QoL). Therefore, a randomized controlled trial comparing CP and QoL after FS fixation of mesh with ST in transabdominal preperitoneal hernioplasty (TAPP) was performed at our department. The primary end point of our study was to assess the patient outcome by using a visual analog scale (VAS) and the short form 36 (SF-36). The evaluation of recurrence rates was the secondary aim. METHODS: According to the randomization, a macroporous mesh (TiMESH(®)) was fixed in group A (44 patients with 54 inguinal hernias) with FS (TISSEEL) or in group B (45 patients with 56 inguinal hernias) with ST (EMS(®) Stapler). The observation period was 1 year with regular clinical check ups and assessment of VAS and SF-36. RESULTS: Patient characteristics expressed by BMI, ASA scores, and Schumpelick hernia classification were similar in both treatment groups. In each group there was one recurrence within 8 (FS) and 9 months (ST) postsurgery. The mean preoperative pain values scored by VAS were 1.7 (range = 0-7.5) in the FS group and 2.2 (range = 0-6) in the ST group. Postoperative mean VAS scores measured at 1 year postsurgery were 0.4 (range = 0-3) in the FS group and 0.9 (range = 0-7.5) in the ST group. One year postsurgery there was no significant difference between the two groups with respect to the parameter pain in the SF-36 and VAS. CONCLUSION: Fibrin sealant fixation leads to a low rate of hernia recurrence and avoids tissue trauma. ST provide similar results in the hand of the expert but bear inherent risks of complications due to tissue perforation.

Pharmacological treatment of chronic pain - the need for CHANGE.

BACKGROUND: Although chronic pain affects around 20% of adults in Europe and the USA, there is substantial evidence that it is inadequately treated. In June 2009, an international group of pain specialists met in Brussels to identify the reasons for this and to achieve consensus on strategies for improving pain management. SCOPE: Literature on chronic pain management was reviewed, and information presented to and discussed by a panel of experts. FINDINGS: It was agreed that guidelines are not universally accepted by those involved in pain management, and pain treatment seems to be driven mainly by tradition and personal experience. Other factors include poor communication between patients and physicians, the side effects of analgesic drugs, and limited individualisation of therapy. Difficulty in maintaining the balance between adequate pain relief and acceptable tolerability, particularly with strong opioids, can lead to the establishment of a 'vicious circle' that alternates between lack of efficacy and unpleasant side effects, prompting discontinuation of treatment. The medical community's understanding of the physiological differences between nociceptive pain and neuropathic pain, which is often more severe and difficult to treat, could be improved. Increasing physicians' knowledge of the pharmacological options available to manage these different pain mechanisms offers the promise of better treatment decisions and more widespread adoption of a multi-mechanistic approach; this could involve loosely combining two substances from different drug classes, or administering an analgesic with two different mechanisms of action. In some circumstances, a single compound capable of addressing both nociceptive and neuropathic pain is desirable. CONCLUSIONS: To improve patient outcomes, a thorough understanding of pain mechanisms, sensitisation and multi-mechanistic management is required. Universal, user-friendly educational tools are therefore required to familiarise physicians with these topics, and also to improve communication between physicians and their pain patients, so that realistic expectations of treatment can be established.

4 years after withdrawal of rofecoxib: where do we stand today?

On the 24th of October 2006, the European Medicines Agency (EMEA) stated that "it cannot be excluded that non-selective non-steroidal anti-inflammatory drugs (nsNSAIDs) may be associated with a small increase in the absolute risk for thrombotic events". Reviewing the most recent literature including meta-analyses of randomized clinical studies and pharmacoepidemiological studies show that this statement contrasts with the 2005 EMEA evaluation of cyclooxygenase-2 inhibitors, which contained a number of regulations including several contraindications for coxibs. Recent clinical data indicate that the entire substance group of NSAIDs may have cardiovascular side effects but to different degrees. Results of basic research support these observations showing that the increase for cardiovascular risk not only depends on the ratio of inhibition of thromboxan and prostacyclin but also on other mechanisms including blood pressure elevation and cyclooxygenase independent actions. In clinical practice, many patients require anti-inflammatory therapy with NSAIDs but are at high cardiovascular and gastrointestinal risk. The combination of nsNSAIDs with proton pump inhibitors shows comparable safety to coxibs in averting upper gastrointestinal events, but evidence is increasing coxibs have advantages regarding lower gastrointestinal side effects. Concomitant therapy with aspirin is another issue. There is a negative effect on gastrointestinal safety, as well as the influence of nsNSAIDs on the cardioprotective effect of aspirin. As the contraindications for coxibs announced by the EMEA may prevent some patients from receiving optimal treatment, a warning for the entire substance group, as issued by the American Food and Drug Administration, with no contraindictions, would certainly be more reasonable.

Plasma D-lactate as a potential early marker for colon ischaemia after open aortic reconstruction.

BACKGROUND AND AIM: The breakdown of mucosal barrier function due to intestinal hypo-perfusion is the earliest dysfunction of ischaemic colitis. Severe colon ischaemia after aortic reconstruction is associated with mortality rates up to 90%. Therefore, early detection and treatment of patients with extensive ischaemic colitis is of crucial importance. In experimental studies, both D-lactate and bacterial endotoxin have been reported as markers of intestinal mucosal barrier impairment. However, evidence of their value in clinical practice is lacking. The aim of this pilot prospective cohort study was to assess the association between ischaemia of the colon (assessed histologically) and plasma levels of D-lactate and endotoxin in patients undergoing open aortic reconstruction. PATIENTS AND METHODS: Twelve consecutive patients underwent surgery between February and April 2003. Six patients underwent emergency surgery and six patients elective aortic surgery. D-Lactate and endotoxin levels were measured in blood samples collected according to a standardised protocol. For histological examination biopsies were obtained by sigmoidoscopy on days 4-6 after surgery, or earlier if indicated clinically. RESULTS: As early as 2 h postoperatively, elevated plasma levels of d-lactate were measured in patients with histologically proven ischaemic colitis. The peak of D-lactate elevation was on postoperative days 1 and 2. Concentration of plasma endotoxin was not significantly different in patients with or without ischaemic colitis. CONCLUSION: Our data suggest that plasma D-lactate levels are a useful marker for early detection of ischaemic colitis secondary to aortic surgery.