Less Induction Time and Postoperative Pain Using Spinal Anesthesia Versus General Anesthesia With or Without the Use of Peripheral Nerve Blocks in Total Knee Arthroplasty.

BACKGROUND: Our aim was to analyze anesthetic induction time and postoperative pain using spinal anesthesia versus general anesthesia with or without the use of peripheral nerve blocks (PNBs) in total knee arthroplasty. The hypothesis was that spinal anesthesia would be beneficial with respect to induction time and postoperative pain and that PNBs would complement this effect. METHODS: Patients were stratified according to demographics, American Society of Anesthesiologists physical status classification system (ASA), and opioid intake and divided into: (A) general anesthesia without PNB; (B) general anesthesia with PNB; (C) spinal anesthesia without PNB; and (D) spinal anesthesia with PNB. Endpoints were anesthetic induction time, opioid consumption, and pain. Of 559 patients, 348 (62.3%) received general anesthesia (consisting of group A with 46 and group B with 302 patients), and 211 (37.7%) spinal anesthesia (consisting of group C with 117 and group D with 94 patients). RESULTS: We observed significantly lower total opioid intake 48 hours postoperative when applying spinal anesthesia by 2.08 mg (P < .05) of intravenous morphine-equivalent, and a reduction of 7.0 minutes (P < .05) until skin incision. The application of a PNB achieved a reduction of piritramide intake of 3.59 mg (P < .05) 48 hours postoperative and lengthened induction time by 8.5 minutes (P < .05). CONCLUSIONS: Statistically shorter anesthetic induction times without clinical relevance, but lower postoperative opioid dosages with clinical relevance were observed for patients undergoing total knee arthroplasty with spinal anesthesia. The additional application of PNBs led to a lower need for opioids and lower pain levels in the early postoperative phase.

Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial.

PURPOSE: Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being. DESIGN: Double-blind randomized controlled trial. METHODS: The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications. FINDINGS: Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present. CONCLUSIONS: This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.

Evaluation of Neuropathic Pain after Total Knee Arthroplasty: Do Yellow Flags Matter?

Up to 20% of total knee arthroplasty (TKA) patients continue to experience chronic postsurgical pain. Various factors have been identified as potential contributors, including so-called "yellow flags", encompassing symptoms of depression, anxiety, and catastrophizing, which were examined in this study to assess their predictive value concerning functional outcomes after TKA. METHODS: Fifty TKA patients were categorized into high-risk and low-risk groups based on clinical assessment, demographic data, medication, and patient-reported outcome measures (DN4, SF-36, WOMAC, NRS, Fibromyalgia Survey Questionnaire, Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale). Postoperative outcomes within six months after TKA were then compared. RESULTS: Both groups exhibited significant (p < 0.001) improvements in all WOMAC and NRS subscales, as well as in the physical function, role physical, pain, and energy/fatigue subdomains of the SF-36 after six months, while the high-risk group showed lower WOMAC scores regarding stiffness (19.0 ± 18.3 vs. 27.2 ± 20.7, p < 0.001) and pain (13.5 ± 13.3 vs. 15.1 ± 16.3, p = 0.029). The high-risk group showed significantly worse preoperative DN4 scores (1.8 ± 1.3 vs. 3.0 ± 1.1, p = 0.002) than the low-risk group, which persisted for one day (2.3 ± 1.2 vs. 3.5 ± 1.5, p = 0.005) and six weeks (2.2 ± 1.9 vs. 3.6 ± 2.3, p = 0.041) postoperatively. CONCLUSIONS: Our results indicate that pre-existing yellow flags contribute to a more challenging early postoperative phase, underscoring the importance of considering individual patient characteristics and psychological factors to optimize TKA outcomes.

Local Periarticular Infiltration with Dexmedetomidine Results in Superior Patient Well-Being after Total Knee Arthroplasty Compared with Peripheral Nerve Blocks: A Randomized Controlled Clinical Trial with a Follow-Up of Two Years.

BACKGROUND: This study aimed to compare local periarticular infiltration (LIA) with ultra-sound guided regional anesthesia (USRA) with ropivacaine and dexmedetomidine as an additive agent in primary total knee arthroplasty (TKA). METHODS: Fifty patients were randomized into two groups in a 1:1 ratio. Patients in the LIA group received local periarticular infiltration into the knee joint. The USRA group received two single-shot USRA blocks. Functional outcomes and satisfaction (range of movement, Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score, and Forgotten Joint Score), including well-being, were analyzed preoperatively and at five days, six weeks, and one and two years postoperatively. RESULTS: Functional outcomes did not significantly differ between the two groups at six weeks and one and two years after the implementation of TKA. A moderate correlation was observed in the LIA group regarding well-being and pain on day five. Six weeks postoperatively, the LIA group showed significantly superior well-being but worse pain scores. No differences between the groups in well-being and functional outcomes could be observed one and two years postoperatively. CONCLUSION: Patients treated with LIA had superior postoperative well-being in the early postoperative phase of up to six weeks. Furthermore, LIA patients had similar functionality compared to patients treated with USRA but experienced significantly more pain six weeks postoperatively. LIA leads to improved short-term well-being, which is potentially beneficial for faster knee recovery. We believe that LIA benefits fast-track knee recovery with respect to improved short-term well-being, higher practicability, and faster application.

Physician utilization in prehospital emergency medical services in Europe: an overview and comparison. / Visión general y comparación de la presencia de médicos en los servicios de emergencias médicas prehospitalarios en Europa.

OBJECTIVES: National and regional systems for emergency medical care provision may differ greatly. We sought to determine whether or not physicians are utilized in prehospital care and to what extent they are present in differentEuropean countries. MATERIAL AND METHODS: We collected information on 32 European countries by reviewing publications and sending questionnaires to authors of relevant articles as well as to officials of ministries of health (or equivalent), representatives of national societies in emergency medicine, or well-known experts in the specialty. RESULTS: Thirty of the 32 of European countries we studied (94%) employ physicians in prehospital emergency medical services. In 17 of the 32 (53%), general practitioners also participate in prehospital emergency care. Emergency system models were described as Franco-German in 27 countries (84%), as hybrid in 17 (53%), and as Anglo-American in 14 (44%). Multiple models were present simultaneously in 17 countries (53%). We were able to differentiate between national prehospital emergency systems with a novel classification based on tiers reflecting the degree of physician utilization in the countries. We also grouped the national systems by average population and area served. CONCLUSION: There are notable differences in system designs and intensity of physician utilization between different geographic areas, countries, and regions in Europe. Several archetypal models (Franco-German, hybrid, and Anglo- American) exist simultaneously across Europe.

OBJETIVO: Los sistemas nacionales y regionales de prestación de atención médica a las emergencias pueden diferir mucho entre sí. Se buscó dilucidar la presencia de médicos en la atención prehospitalaria y su implantación en los diferentes países europeos. METODO: Se analizaron los datos de 32 países europeos recogidos mediante la revisión de artículos publicados y a través de cuestionarios enviados a los autores de artículos científicos pertinentes, funcionarios del ministerio de sanidad (o equivalente), representantes de sociedades nacionales de medicina de urgencias o expertos reconocidos en medicina de urgencias. RESULTADOS: Treinta de los 32 países europeos investigados (94%) disponen de médicos en los servicios de emergencias prehospitalarios. En 17 de 32 (53%), los médicos generalistas también participan en la atención a las emergencias prehospitalarias. Los modelos de los sistemas de emergencias médicas (SEM) se describieron como francoalemanes en 27 países (84%), híbridos en 17 (53%) o angloamericanos en 14 (44%). En 17 países (53%), coexistían diferentes modelos. Utilizando una nueva forma de clasificación por niveles, basada en la población media y el área atendida por el SEM prehospitalario, se pudieron diferenciar claramente los diferentes modelos existentes. CONCLUSIONES: Se observan notables diferencias en los diseños de los SEM y en la presencia de los médicos entre las diferentes áreas geográficas, países y regiones de Europa. Coexisten varios modelos (francoalemán, híbrido y angloamericano), algunos simultáneamente, en los diferentes países.

Visión general y comparación de la presencia de médicos en los servicios de emergencias médicas prehospitalarios en Europa / Physician utilization in prehospital emergency medical services in Europe: an overview and comparison

Antecedentes: Los sistemas nacionales y regionales de prestación de atención médica a las emergencias pueden diferir mucho entre sí. Se buscó dilucidar la presencia de médicos en la atención prehospitalaria y su implantación en los diferentes países europeos. Métodos: Se analizaron los datos de 32 países europeos recogidos mediante la revisión de artículos publicados y a través de cuestionarios enviados a los autores de artículos científicos pertinentes, funcionarios del ministerio de sanidad (o equivalente), representantes de sociedades nacionales de medicina de urgencias o expertos reconocidos en medicina de urgencias. Resultados: Treinta de los 32 países europeos investigados (94%) disponen de médicos en los servicios de emergencias prehospitalarios. En 17 de 32 (53%), los médicos generalistas también participan en la atención a las emergencias prehospitalarias. Los modelos de los sistemas de emergencias médicas (SEM) se describieron como francoalemanes en 27 países (84%), híbridos en 17 (53%) o angloamericanos en 14 (44%). En 17 países (53%), coexistían diferentes modelos. Utilizando una nueva forma de clasificación por niveles, basada en la población media y el área atendida por el SEM prehospitalario, se pudieron diferenciar claramente los diferentes modelos existentes. Conclusiones: Se observan notables diferencias en los diseños de los SEM y en la presencia de los médicos entre las diferentes áreas geográficas, países y regiones de Europa. Coexisten varios modelos (francoalemán, híbrido y angloamericano), algunos simultáneamente, en los diferentes países. (AU)

Background: National and regional systems for emergency medical care provision may differ greatly. We sought to determine whether or not physicians are utilized in prehospital care and to what extent they are present in different European countries. Methods: We collected information on 32 European countries by reviewing publications and sending questionnairesto authors of relevant articles as well as to officials of ministries of health (or equivalent), representatives of national societies in emergency medicine, or well-known experts in the specialty. Results: Thirty of the 32 of European countries we studied (94%) employ physicians in prehospital emergency medical services. In 17 of the 32 (53%), general practitioners also participate in prehospital emergency care. Emergency system models were described as Franco-German in 27 countries (84%), as hybrid in 17 (53%), and as Anglo-American in 14(44%). Multiple models were present simultaneously in 17 countries (53%). We were able to differentiate between national prehospital emergency systems with a novel classification based on tiers reflecting the degree of physician utilization in the countries. We also grouped the national systems by average population and area served. Conclusions: There are notable differences in system designs and intensity of physician utilization between different geographic areas, countries, and regions in Europe. Several archetypal models (Franco-German, hybrid, and AngloAmerican) exist simultaneously across Europe. (AU)

Prolonged sedation with sevoflurane in comparison to intravenous sedation in critically ill patients - A randomized controlled trial.

BACKGROUND: Volatile anesthetics are used more commonly for sedation in the intensive-care-unit (ICU). However, evidence for long-term use remains low. We therefore conducted a randomized-controlled trial comparing sevoflurane with intravenous sedation with particular focus on efficacy and safety. METHODS: In this prospective, randomized-controlled phase-IIb monocentric clinical-trial ICU patients requiring at least 48 h of sedation were randomized to receive sevoflurane (S) or propofol/midazolam (P). Sedation quality was monitored using the Richmond-Agitation-Sedation-Scale. Following termination of sedation, the time to spontaneous breathing and extubation, opioid consumption, hemodynamics, ICU and hospital length of stay (LOS) and adverse events were recorded. RESULTS: 79 patients were eligible to randomization. Sedation quality was comparable between sevoflurane (n = 39) and propofol (n = 40). However, the use of sevoflurane lead to a reduction in time to spontaneous breathing (26 min vs. 375 min, P < 0.001). Patients sedated with propofol had lower opioid requirements (remifentanil:400 µg/h vs. 500 µg/h, P = 0.007; sufentanil:40 µg/h vs. 30 µg/h, P = 0.007) while hemodynamics, LOS or the occurrence of adverse events did not differ. CONCLUSION: ICU patients sedated with sevoflurane >48 h may return to spontaneous breathing faster, while the quality of sedation is comparable to a propofol-based sedation regime. Sevoflurane might be considered to be safe for long-term sedation in this patient population, while being non-inferior compared to propofol.

[Functional and morphological disorders of taste and olfaction in COVID-19 patients]. / Funktionelle und morphologische Geschmacks- und Geruchsstörungen bei COVID-19-Patienten.

OBJECTIVE: This study aimed to test the prevalence and evolution of acute olfactory and gustatory functional impairment and their morphologic correlates in COVID-19 patients who require hospitalization due to COVID-19-related respiratory conditions. METHODS: Included were 53 consecutive hospitalized patients (23 males, 30 females; age 42.54 ± 10.95 years) with an RT-PCR-confirmed COVID-19 diagnosis. Patients were examined twice: just after hospital discharge and 4-6 weeks later. Electrogustometric (EGM) thresholds at the tongue area supplied by the chorda tympani, at the soft palate, and in the region of the vallate papillae were recorded bilaterally. Olfaction was examined by Sniffin' sticks (Burghardt GmbH, Wedel, Germany). The patients' nasal and oral mucosa (fungiform papillae, fpap) were examined by contact endoscopy. Findings were compared to those of 53 healthy individuals matched for sex and age (23 males, 30 females; age 42.90 ± 10.64 years). RESULTS: EGM thresholds in patients were significantly higher than those of healthy subjects at both timepoints. EGM thresholds at the second measurement were significantly lower than those at the first measurement. Accordingly, patient-reported gustatory outcomes were improved at the second measurement. The same pattern was found using Sniffin' sticks. Significant alterations in form and vascularization of fPap were detected in patients, especially at the first instance. Interestingly we did not observe any significant changes in the morphology and vascularization of nasal mucosa. CONCLUSION: COVID-19 affects both gustatory and olfactory functions. In parallel, it also affects the structure and vascularization of both nasal and oral mucosa, albeit the nasal mucosa to a much lesser, non-significant extent. Our findings suggest that COVID-19 may cause a mild to profound neuropathy of multiple cranial nerves.

Combined femoral and popliteal nerve block is superior to local periarticular infiltration anaesthesia for postoperative pain control after total knee arthroplasty.

INTRODUCTION: After primary total knee arthroplasty (TKA), local periarticular infiltration anaesthesia (LIA) is a fast and safe method for postoperative pain control. Moreover, ultrasound-guided regional anaesthesia (USRA) with femoral and popliteal block is a standard procedure in perioperative care. Two analgesic regimens for TKA-LIA versus URSA with dexmedetomidine-were compared as an additive to ropivacaine. We hypothesised that the use of URSA provides a superior opioid sparing effect for TKA compared with LIA. METHODS: Fifty patients (planned 188 participants; safety analysis was performed after examining the first 50 participants) were randomised. These patients received LIA into the knee capsule during surgery with 60 ml of ropivacaine 0.5% and 1 ml of dexmedetomidine (100 µg ml-1) or two single-shot URSA blocks (femoral and popliteal block) before surgery with 15 ml of ropivacaine 0.5% and 0.5 ml of dexmedetomidine for each block. Postoperative opioid consumption in the first 48 h, pain assessment and complications were analysed. RESULTS: In the safety analysis, there was a significantly higher need for opioids in the LIA group, with a median oral morphine equivalent of 42.0 [interquartile range (IQR) 23.5-57.0] mg versus 27.0 [IQR 0.0-33.5] mg (P = 0.022). Due to this finding, the study was terminated for ethical considerations according to the protocol. CONCLUSION: This is the first study presenting data on LIA application in combination with dexmedetomidine. A superior opioid-sparing effect of URSA was observed when compared with LIA in TKA when dexmedetomidine is added to local anaesthetics. Also, a longer lasting opioid-sparing effect in the LIA group was observed when compared with the recently published literature; this difference could be attributed to the addition of dexmedetomidine. Therefore, multimodal analgesia regimens could be further improved when LIA or USRA techniques are combined with dexmedetomidine.

[Role of Dexamethasone for Pain Management in Intervertebral Disc Surgery]. / Dexamethason für die postoperative Schmerztherapie in der Bandscheibenchirurgie.

Intervertebral disc operations are already among the most common and their frequency is increasing. The pain associated with these operations is one of the most common postoperative discomforts, has a significant impact on psychosocial aspects, and should therefore be treated effectively. Therefore, we present the importance of dexamethasone for multimodal pain management after intervertebral disc surgery.

The Austrian ICU survey : A questionnaire-based evaluation of intensive care medicine in Austria.

BACKGROUND: While structures of intensive care medicine in Austria are well defined, data on organisational and medical practice in intensive care units (ICUs) have not been systematically evaluated. METHODS: In this explorative survey, organisational and medical details of ICUs in Austria were collected using an online questionnaire consisting of 147 questions. RESULTS: Out of 249 registered ICUs 73 (29.3%) responded, 60 were adult, 10 pediatric/neonatal ICUs and 19, 25 and 16 ICUs were located in level I, II and III hospitals, respectively. Of the respondents 89% reported that the ICU director was board-certified in intensive care medicine. Consultants were constantly present in 78% of ICUs during routine working hours and in 45% during nights and weekends. The nurse:bed ratio varied between 1:1 and 1:2 in 74% during day shifts and 60% during night shifts. Routine physiotherapist rounds were reported to take place daily except weekends in 67% of ICUs. Common monitoring techniques were reported to be in routine or occasional use in 85% and 83% of ICUs, respectively. The majority of ICUs provided daily visiting hours ranging between 2-12 h. Waiting rooms for relatives were available in 66% and an electronic documentation system in 66% of ICUs. Written protocols were available in 70% of ICUs. CONCLUSION: The Austrian ICU survey suggests that ICUs in Austria are clearly structured, well-organized and well-equipped and have a high nurse:bed ratio. In view of the relatively low return rate we cannot exclude that a selection bias has led to overestimation of the survey findings.

[Post-polio Syndrome in the Perioperative Phase]. / Das Post-Polio-Syndrom in der perioperativen Phase.

Due to the numerous poliomyelitis epidemics that have continued over the last decades and the post-polio syndrome (PPS) that occurs 10 - 30 years after poliomyelitis infection, the prevalence of PPS is also expected to increase in Europe. At the same time, due to the musculoskeletal disorders associated with the underlying disease, PPS patients often require surgery for which special anaesthetic requirements must be taken into account. In this analysis we summarise the current evidence and recommendations.

Google Trends for Pain Search Terms in the World's Most Populated Regions Before and After the First Recorded COVID-19 Case: Infodemiological Study.

BACKGROUND: Web-based analysis of search queries has become a very useful method in various academic fields for understanding timely and regional differences in the public interest in certain terms and concepts. Particularly in health and medical research, Google Trends has been increasingly used over the last decade. OBJECTIVE: This study aimed to assess the search activity of pain-related parameters on Google Trends from among the most populated regions worldwide over a 3-year period from before the report of the first confirmed COVID-19 cases in these regions (January 2018) until December 2020. METHODS: Search terms from the following regions were used for the analysis: India, China, Europe, the United States, Brazil, Pakistan, and Indonesia. In total, 24 expressions of pain location were assessed. Search terms were extracted using the local language of the respective country. Python scripts were used for data mining. All statistical calculations were performed through exploratory data analysis and nonparametric Mann-Whitney U tests. RESULTS: Although the overall search activity for pain-related terms increased, apart from pain entities such as headache, chest pain, and sore throat, we observed discordant search activity. Among the most populous regions, pain-related search parameters for shoulder, abdominal, and chest pain, headache, and toothache differed significantly before and after the first officially confirmed COVID-19 cases (for all, P<.001). In addition, we observed a heterogenous, marked increase or reduction in pain-related search parameters among the most populated regions. CONCLUSIONS: As internet searches are a surrogate for public interest, we assume that our data are indicative of an increased incidence of pain after the onset of the COVID-19 pandemic. However, as these increased incidences vary across geographical and anatomical locations, our findings could potentially facilitate the development of specific strategies to support the most affected groups.