[THE CHOICE OF PERIOPERATIVE MULTIMODAL ANALGESIA IN PATIENTS WITH LUMBAR HERNIATED DISC: THE PRELIMINARY RESULTS.]

DESIGN: 129 patients scheduled for elective lumbar discectomy in 2010-2013 were enrolled in prospective study. Group K (n=20) underwent general anaesthesia and postoperative analgesia on-demand. Group PMA+SA (n=23) got subarachnoid block and preventive multimodal analgesia (PMA) including ketoprofen, paracetamol and nalbuphine. At PMA group (n=21) general anaesthesia and PMA were used; at PMA+I (n=21) also bupivacaine wound infiltration was administrated; at PlvL4+S (n=20) - depo-corticosteroid was applied locally on affected spinal nerve root; at PMA+IS (n=24) wound infiltration and local corticosteroids were combined. Patients could use i.v. nalbuphine on-demand by PCA device in addition to PMA post-operatively. 7 days post-operatively, the pain scores using 10 cm VAS at rest and during movement were also recorded. RESULTS: Group K patients had not adequate pain relief during 4 postoperative days. At PMA group the postoperative analgesia was adequate during the whole assessment time, PMA group patients had significant less pain scores than at K group during 4 postoperative days. Patients at PM +SA had better than PMA group pain relief only during 2 hours postoperatively. Groups PMA+I and PMA+IS did not demand nalbuphine at al. Their pain scores were signifcant less than at PMA group during 2 postoperative days. CONCLUSIONS: Postoperative analgesia on-demand is not adequate but the PMA is. Subarachnoid block results in decreasing severity of pain only during first hours postoperatively. The additional bupivacaine wound infiltration in pa- tients with lumbar herniated disc follows avoiding of opioids and significant pain relief during 2 postoperative days.

[INTRATHECAL OPIOID ANALGESIA - STATE IN THE WORLD AND IN THE RUSSIAN FEDERATION].

Intrathecal opioid analgesia has been used in clinic practice since 1979 and has gained a great popularity till now due to its high analgesic potency Unfortunately it is impossible to use opioids intrathecally in Russian Federation by law because of nowadays official limitations. Russian national anaesthesiologic society should comprehend benefits and side effects of this method and make a decision if it is worth fighting for.

[Predicting of postoperative pain level and morphine consumption by preoperative pressure pain assessment in patients before elective surgery].

UNLABELLED: The aim of this study was to predict a postoperative pain severity and morphine consumption by preoperative pressure pain assessment. DESIGN: 321 patients scheduled for elective surgery (lumbar discectomy, lumbar spinal fusion, hysterectomy, thoracotomy and total hip replacement) in 2009-2013 were enrolled in retrospective study. Pre-operatively, the pain threshold (PTH) and tolerance (PT) in Newton (N) were measured using the pressure algometry. Post-operatively, the pain scores at rest and during movement at 1st postoperative day (POD) using 10 cm VAS were also recorded Patients could get morphine by PCA device in addition to nonopioid analgesia post-operatively. RESULTS: PTH and PT were respectively 34 (24; 45.6) and 74 (54; 95) N, VAS at 1 POD 2 (1; 3.75) at rest and 4 (2,5; 6.25) cm during movement. Pre-operative PT correlated significantly with pain score during movement in patients at 1 POD (R = -0.124, p = 0.026, n = 320). Logit regression analysis found that pain control adequacy during movement at 1 POD could be predicted with PT (ß = 0.011, Std. Err = 0.004, χ2 = 8.536, p = 0.004, OR = 1.011, 95% CI = 1.004-1.018). Morphine consumption by PCA device in patients was 21.25 (7.5; 38) mg. We found a significant correlation between pre-operative PT and post-operative morphine consumption (R = -0.306, p = 0.0006, n = 122). CONCLUSIONS: Post-operative pain severity during movement at 1st postoperative day can be predicted with the pre-operative pain tolerance using the pressure algometry. There is significant moderate negative correlation between pre- operative pain tolerance and post-operative morphine consumption by PCA device in patients at 1st postoperative day.

[Assessment of pain relief in patients receiving different variants of multimodal analgesia after major gynecological surgery].

The major gynecology surgery generally results in severe postoperative pain. Currently multimodal analgesia concept is widely used for the aim of postoperative pain relief optimization. According to this theory it is worth using the medication with different mechanism in order to increase analgesia qualify, decrease analgesic consumption and avoid adverse reaction. Unfortunately the surveys recently conducted have been pointed out the postoperative analgesia quality is still insufficient despite of using the concept mentioned above. One way to solve the problem is appearing in daily practice nefopam--centrally acting non-opioid analgesic that inhibits reuptake of serotonin, norepinephrine, and dopamine and also mitigates glutamatergic neurotransmission. In this trial we tried to assess the postoperative daily used analgesia quality and potency of preemptive multimodal analgesia model consisted of nefopam, ketoprofen, paracetamol and morphine.

Acute myocardial infarction: OPCAB is an alternative approach for treatment.

BACKGROUND: Mortality in intensive care units among patients with acute myocardial infarction (AMI) may reach 10-20%, and with cardiogenic shock 50-100%. Moreover, the mortality rate at one year is about 15%, and 25-40% of survivors suffer from recurrent angina. In this report, we describe the surgical results of high-risk patients with AMI who were operated on within 96 hours of the infarction. METHODS: From January 1998 through July 2000, among 348 patients who underwent off-pump coronary surgery at the [institution removed for review], 26 consecutive patients (7.5%) were operated on for acute myocardial infarction. Patients with AMI secondary to failed percutaneous transluminal coronary angioplasty (PTCA) were not included in the study group. Four patients (15.3%) were admitted to surgery in cardiogenic shock, four (15.3%) with life-threatening ventricular arrhythmias, and one patient with a rupture of the posterior left ventricular wall. Repeated ventricular fibrillations were recorded in the operating room in three patients (11.5%). In 16 patients, conventional off-pump coronary artery bypass (OPCAB) surgery through median sternotomy was performed using 1-3 saphenous vein grafts, and 10 patients underwent minimally invasive coronary artery bypass (MICAB) with the endoscopic dissection of the left internal mammary artery (LIMA) for single- or double-vessel revascularization. RESULTS: A mean time of 620 +/- 45 minutes (range 180 min. to 96 hours) was recorded between first symptoms and surgical reperfusion. The mortality rate was 7.7% (N = 2). Major complications, which included cerebrovascular accident (CVA), were observed in one patient and resulted in a morbidity rate of 3.8%. The mean number of grafts per patient was 1.8. Twenty-two patients (84.6%) underwent complete revascularization, but four patients (15.4%) with multivessel coronary disease and unstable hemodynamics received incomplete revascularization as a result of not grafting the obtuse marginal or posterior lateral branches of the circumflex coronary artery. In the early postoperative period, all patients were asymptomatic. Early angiographic study was undertaken from five to fifteen days postoperatively in 12 patients (46%); the angiography demonstrated the patency of all studied grafts and the recovery of left ventricular function. CONCLUSION: Off-pump coronary surgery after AMI can be performed with an acceptable mortality rate and low risk of major complications, and offers prospects for early rehabilitation.