Management of Aneurysmal Subarachnoid Haemorrhage and its Complications: A Clinical Guide.

Aneurysmal subarachnoid hemorrhage (aSAH) is an emergency that needs prompt diagnosis and treatment with endovascular coiling or surgical clipping of the aneurysm to prevent re-bleeding. In addition to neurologic manifestations, aSAH can cause respiratory and cardiovascular complications. The prevention of hypoxemia and hypercarbia, control of intracranial pressure, and restoration of cerebral perfusion pressure should be the primary aims of early management. Secondarily, the most important causes of persistent neurological deficits and physical dependence in aSAH are vasospasm and delayed ischemia following bleeding. During that period, a focus on the detection, prevention, and treatment of vasospasm should be the rule. Transcranial Doppler allows detection and follow-up of vasospasm, especially in severe cases. Nimodipine is the only drug that has proven efficacy for treating vasospasm. Balloon angioplasty is performed in cases of resistance to medical treatment. Along with angioplasty, intra-arterial vasodilators can be administered. New diagnostic and therapeutic advances will hopefully improve outcomes in the near future.

The role of "Integrated Pulmonary Index" monitoring during morphine-based intravenous patient-controlled analgesia administration following supratentorial craniotomies: a prospective, randomized, double-blind controlled study.

OBJECTIVE: Morphine is commonly used in post-operative analgesia, but opioid-related respiratory depression causes a general reluctance for its use. The "Integrated Pulmonary Index" is a tool calculated from non-invasively obtained respiratory and hemodynamic parameters. The aim of this prospective, randomized, double blind, and placebo-controlled study is to determine a more safe and effective dose for morphine in patient-controlled analgesia following supratentorial craniotomy using the "Integrated Pulmonary Index". METHODS: This study included 60 patients (ASA I, II, and III). All patients used iv PCA for 24 h following supratentorial craniotomy. The PCA was set to administer a bolus dose of 1 mg morphine in Group 1 and 0.5 mg morphine in Group 2. The PCA contained placebo in Group 3 and patients received dexketoprofen 50 mg iv after awakening, repeated every 8 h. The IPI and NRS scores, total morphine consumption, and morphine related side-effects were recorded at 10 min, 1, 2, 6, 12, and 24 h post-operatively. The lowest IPI score, count of apnea, and desaturation events were recorded during the study period. RESULTS: The IPI scores were similar among the groups. Although a statistically significant difference was not observed among the groups the lowest IPI scores were observed in Group 1; apnea and desaturation counts were also higher in Group 1. Statistically significant differences were not observed among the groups in terms of pain scores, but were lower in Groups 1 and 2 compared to Group 3. CONCLUSION: Patient controlled analgesia with 0.5 mg morphine may be safe and effective for pain management following supratentorial craniotomies. Integrated pulmonary index can be used for detecting opioid-induced respiratory depression. Clinical Trials registration number: NCT02929147.

Efficacy of intravenous paracetamol, metamizol and lornoxicam on postoperative pain and morphine consumption after lumbar disc surgery.

BACKGROUND AND OBJECTIVE: The combination of opioids with supplemental analgesics is commonly used for additive or synergistic analgesic effects. We aimed to determine the most advantageous supplemental analgesic for postoperative pain relief after lumbar disc surgery. METHODS: This prospective, placebo-controlled, randomized, double-blind study compared the effects of intravenous metamizol, paracetamol and lornoxicam on postoperative pain control, morphine consumption and side effects after lumbar disc surgery. Eighty patients with American Society of Anesthesiologists classification 1 or 2 scheduled for elective lumbar disc surgery under general anaesthesia were treated using patient-controlled analgesia with morphine until 24 h postoperatively and randomized to receive additional intravenous injections of metamizol 1 g, paracetamol 1 g, lornoxicam 8 mg or isotonic saline 0.9% (placebo). The primary endpoint was pain over 24 h after surgery measured by visual analogue scale. Secondary endpoints were morphine consumption and side effects. RESULTS: During the 24 h study period, pain was reduced in the metamizol (P = 0.001) and paracetamol (P = 0.04) groups, but not in the lornoxicam (P = 0.20) group compared with the control group. Further analysis revealed that pain scores in the metamizol group were significantly lower than in the lornoxicam group (P = 0.031). Although the rate of morphine consumption in the paracetamol group was decreased over time (P < 0.001), the total amounts of morphine consumed in 24 h were not different between groups. No significant differences with respect to morphine-related side effects were observed between groups. CONCLUSION: Metamizol or paracetamol, but not lornoxicam, provides effective analgesia following lumbar disc surgery.