Contraindications to regional anaesthesia in obstetrics: a survey of German practice

BACKGROUND

We assessed current practice regarding indications and contraindications to regional analgesia and anaesthesia for labour and delivery in Germany.

METHODS

Questionnaires were mailed to the directors of 918 German departments of anaesthesiology.

RESULTS

A total of 397 completed replies were received representing 41.3% of all deliveries in Germany. More than half of the respondents never perform spinal or epidural anaesthesia when the platelet count falls below 65x10(9)/L. Preeclampsia, which was not graded for severity, was considered an absolute contraindication to regional block by 15% and placenta praevia by 30% of respondents. If a woman had taken aspirin three days before, the numbers of respondents considering epidural anaesthesia contraindicated (40.2%) were nearly double those considering spinal anaesthesia contraindicated (21.7%) (P<0.001). For a platelet count of 79x10(9)/L, epidural anaesthesia was thought to be contraindicated by 37% and spinal anaesthesia by 22.2% (P=0.001). In departments with <500 deliveries/year, reluctance to use regional blockade was more pronounced than in departments with >1000 deliveries/year.

CONCLUSION

Clinical practice varies considerably in Germany. Concerns regarding the use of regional blockade were more prevalent in hospitals with small delivery units. Indications and contraindications are not consistent in Germany and some recommendations or guidelines are needed.

Weak opioids--an educational substitute for morphine?

The World Health Organization guidelines suggest the use of weak opioids on the second step of the analgesic ladder for cancer pain relief. Weak opioids are important substitutes for low doses of morphine, although their analgesic efficacy is lower than that of non-opioid or strong opioid analgesics. The use of weak opioids has great educational impact and has helped spread the use of the guidelines. Furthermore, weak opioids are more freely available and are expected to have a better side-effect profile. Controlled long-term studies are required for confirmation.

Prospektive Erfassung der direkten und indirekten Kosten des idiopathischen Parkinson-Syndroms

Idiopathic Parkinson's disease is a chronic progressive neurodegenerative disorder that remains refractory to curative treatment. Most patients are afflicted for many years, and the disease frequently results in severe physical handicap. Statements on the considerable cost of treatment are largely based on estimates and retrospective studies. To obtain more substantial data, we conducted a 3-year study of the economic aspects. Direct and indirect costs incurred by 117 patients (78 male, mean age 67.5 years) at the Deutsche Klinik für Diagnostik in Wiesbaden, Germany, were prospectively followed. The average cost per patient and month ran to <euro> 1007.55. Of that, direct costs amounted to <euro> 603.33 (55.9%), with drugs taking up the major share at <euro> 480.23. Indirect costs were <euro> 404.22 per patient and month, with 76% thereof related to nursing care and the incapacity to earn a living. Cost increased in proportion to Hoehn and Yahr stage, declining again with stages 4 and 5. The data we gathered confirm that Parkinsonism is responsible for sizeable expenses for not only the treating unit but the national economy as a whole.

Change in anaesthetic practice for Caesarean section in Germany

BACKGROUND

Initial data from 1996 revealed that in contrast to several other countries general anaesthesia was the preferred anaesthetic technique for Caesarean section in Germany. However, anaesthetic practice for Caesarean section has changed during the last decades world-wide. This investigation was performed to obtain more actual data on anaesthetic procedures in obstetric patients in German hospitals.

METHODS

Questionnaires on the practice of anaesthesia for Caesarean section were mailed to 918 German departments of anaesthesiology. Furthermore, the survey evaluated severe perioperative complications in obstetric patients.

RESULTS

The 397 completed replies in this survey represent 41.3% of all German deliveries in 2002. Spinal anaesthesia is now the most common technique (50.5%) for elective Caesarean section. In case of urgent and emergency Caesarean, delivery figures decrease to 34.6% and 4.8%, respectively. Epidural anaesthesia is performed in 21.6% of scheduled and 13.2% and 1.0% of non-scheduled urgent or emergency Caesarean sections, respectively. Four maternal deaths and several non-fatal episodes of gastric content aspiration were reported by the respondents.

CONCLUSIONS

Compared to data obtained 6 years ago a significant increase in regional anaesthesia for Caesarean section has developed, with spinal anaesthesia being the preferred technique. Surveys can help to initiate discussion and improve current practice of anaesthetic care.

Die indirekten Kosten des idiopathischen Parkinson-Syndroms

The economic impact of parkinsonism has been getting more significant due to the increasing prevalence of Parkinson's disease and the modern therapies available nowadays. The present study is supposed to update the existing databases and to provide a sound foundation for rational decision-making in the health care sector. It does not only focus on the direct costs of this disease incurred by 75 patients over a longer period, but also and for the first time, takes a look on the indirect cost as well. The study shows that the expenses for PD-related house rebuilding and early retirement make up for a substantial share among the indirect costs. In the overall analysis, the ratio between both, direct and indirect costs appear to be relatively balanced with slight domination of the direct costs.

[Regulation of spinal nociceptin expression by neuropathic pain]

Nociceptin is the endogenous ligand of a new opioid receptor, the opioid receptor-like-1 (ORL1) receptor. Chronic inflammatory pain causes an increase in the expression of nociceptin and the ORL1 receptor in the dorsal horn of rat spinal cord, thus indicating an involvement of the endogenous nociceptin/ORL1 system in mechanisms of pathological pain. This study investigates the influence of neuropathic pain on the expression of nociceptin using immunohistochemistry. To induce neuropathic pain, a ligation of the sciatic nerve was performed in 12 rats under general anesthesia. A sham operation was performed in 12 rats of the control group. Nerve ligation caused a significant ipsilateral thermal hyperalgesia, a typical sign of neuropathic pain. The paw withdrawal latency was decreased by 45.7+/-4.9% ( p<0.05) at day 5 and by 37.3+/-1.8% ( p<0.05) at day 10. Although hyperalgesia was fully present after 5 days, no changes in nociceptin immunoreactivity in the lumbar spinal cord were detected at this time point. Ten days after nerve ligation, there was a 2.46+/-0.38 fold ( p<0.05) bilateral increase in nociceptin immunoreactivity in the lamina superficiales (I and II), with a notable increase in the inner lamina II at the level of L4. Further investigations are necessary to elucidate the relationship between neuropathic pain, the nociceptin-ORL1 receptor system and potential therapeutic options.

5-Hydroxytryptamine-induced plasma extravasation in the rat knee joint is mediated by multiple prostaglandins

OBJECTIVE AND DESIGN

This study investigated whether prostaglandins (PGs) are involved in 5-hydroxytryptamine (5-HT)-induced synovial plasma extravasation.

MATERIALS AND METHODS

Male Sprague-Dawley rat knee joints were perfused with 5-HT and synovial capillary Evans Blue dye leakage was measured using spectrophotometry. Cyclooxygenase (COX) inhibitors and PG receptor subtype-selective antagonists were tested for the ability to reduce 5-HT-induced synovial plasma extravasation.

RESULTS

5-HT-induced plasma extravasation was inhibited by indomethacin. The COX-1 selective inhibitor SC-560 and the COX-2 selective inhibitor NS-398 were equally effective, indicating that both isoforms are involved. Antagonists selective for EP1, EP2 and DP receptor subtypes significantly attenuated the 5-HT-induced plasma extravasation. However, antagonists selective for FP, IP and TP subtypes failed to reduce 5-HT-induced plasma extravasation.

CONCLUSIONS

These results demonstrate that multiple, but selective, subtypes of PGs mediate synovial plasma extravasation produced by 5-HT, and suggest that PGs act downstream of 5-HT in the inflammatory cascade.

[Nociceptin and the ORL1 receptor: pharmacology of a new opioid receptor]

Molecular biological investigations led to the discovery of the ORL1 receptor ( opioid receptor like-1 receptor) and its endogenous ligand nociceptin. Although its sequence and structure are closely related to traditional opioid receptors, the ORL1 receptor shows low binding affinities for selective opioid agonists and antagonists. On the other hand, the ORL1 ligand nociceptin does not bind to the three traditional opioid receptors. The activation of the G protein-coupled ORL1 receptor inhibits adenlylate cyclase activity, reduces the intracellular concentration of the second messenger cAMP and regulates ion channels. The supraspinal administration of nociceptin produces hyperalgesia. unlike opioids. Spinal intrathecal and peripheral administration of nociceptin causes hyperalgesia in low doses and analgesia in high doses. The physiological role and detailed mechanisms of these dose-dependent nociceptin effects in opposite directions are not yet known. In addition, nociceptin modulates other biological phenomena such as feeding, locomotion, gastrointestinal function,memory, cardiovascular function,immunity, renal function, anxiety,dependence and tolerance.Future research on the physiological and pathophysiological importance of the nociceptin/ORL1 receptor systems may provide a target for novel therapeutics.

[Development and state of the in-patient palliative care institutions in Germany]

In April 1999 altogether 114 inpatient units providing palliative care (50 palliative care units, 64 inpatient-hospices) offered a total of 989 beds. Compared to 1993 this has been an increase of 256%, compared to 1997 of 60%. The number of available beds, compared to 1997, increased markedly (58%), with a availability of 12 beds per one million residents. However, there are still major deficits: the distribution of the units is very irregular and the number of available beds is still to low, compared to the estimated need of 50 inpatient beds per one million residents. The quality of palliative care shows significant deficits (e. g. the availability of nursing staff, cooperation with pain clinics, standardised documentation, education). Differences between palliative care wards and hospices were huge. According to the definition of the German Society for Palliative Care, a palliative care ward should provide a ratio of at least 1.4 nursing staff per bed, however, only 18% of the palliative care units fulfil this definition. Only few hospices and half of the palliative care units worked in close cooperation with pain clinics. Despite a significant increase in units and inpatient beds providing palliative care, there still is a major deficit in the overall number of beds and the quality of palliative care.

Alternative exon splicing of cyclic AMP response element-binding protein in peripheral sensory and sympathetic ganglia of the rat

Alternative splicing patterns of cyclic AMP response element-binding protein (CREB) in dorsal root ganglia, lumbar sympathetic ganglia and several peripheral tissues of the rat have been investigated by an exon-flanking polymerase chain reaction strategy. A series of RT-PCR with primer pairs flanking all possible alternative splicing sites (corresponding to a genomic region with at least one full exon and two flanking introns) has revealed multiple tissue specific splice variants. These include some novel transcripts that lack the phosphorylation site and part of the leucine zipper region which is crucial for dimerization and DNA binding. Some isoforms previously reported as testis-specific were also detected in rat peripheral ganglia and other tissues. Notably, splicing patterns are specific for some regions. Some of the splice variants indicate inhibitory functions due to lacking phosphorylation sites or partially missing DNA-binding or leucine zipper domains. These findings suggest a complex expression and functional regulation of CREB in peripheral tissues including dorsal root and sympathetic ganglia.

High-dose tramadol in comparison to low-dose morphine for cancer pain relief

Cancer pain treatment following the World Health Organization guidelines is effective and feasible. However, the evidence supporting the use of opioids for mild to moderate pain on the second step of the analgesic ladder is widely discussed. The present evaluation compares the efficacy and safety of high doses of oral tramadol (> or = 300 mg/d) with low doses of oral morphine (< or = 60 mg/d). Patients were included in this nonblinded and nonrandomized study if the combination of a nonopioid analgesic and up to 250 mg/d of oral tramadol was inadequate. 810 patients received oral tramadol for a total of 23,497 days, and 848 patients received oral morphine for a total of 24,695 days. The average dose of tramadol was 428 +/- 101 mg/d (range 300-600 mg/d); the average dose of morphine was 42 +/- 13 mg/d (range 10-60 mg/d). Additional nonopioid analgesics were given on more than 95% of days. Antiemetics, laxatives, neuroleptics, and steroids were prescribed significantly more frequently in the morphine group; the use of other adjuvants was similar in both groups. The mean pain intensity on a 0-100 numerical rating scale (NRS) was 27 +/- 21 (95% CI 26-29) in the tramadol and 26 +/- 20 (95% CI 24-27) in the morphine group (NS). The analgesic efficacy was good in 74% and 78%, satisfactory in 10% and 7%, and inadequate in 16% and 15% of patients receiving tramadol and morphine, respectively (NS). Constipation, neuropsychological symptoms, and pruritus were observed significantly more frequently with low-dose morphine; other symptoms had similar frequencies in both groups. These data suggest that tramadol can be used for the treatment of cancer pain, when nonopioids alone are not effective. High doses of tramadol are effective and safe.

Serum concentrations of tramadol enantiomers during patient-controlled analgesia

AIMS

Tramadol, a centrally acting analgesic, is used as a racemate containing 50% of a (+)- and 50% of a (-)-enantiomer. This paper presents the pharmacokinetic results of postoperative patient-controlled analgesia using (+)-tramadol, (-)-tramadol or the racemate.

METHODS

Ninety-eight patients recovering from major gynaecological surgery were treated in a randomised, double-blind study with (+)-tramadol, (-)-tramadol or the racemate. Following an i.v. bolus up to a maximum of 200 mg, patient-controlled analgesia with demand doses of 20 mg was made available for 24 h. Prior to each demand, the serum concentrations of the enantiomers of tramadol and its metabolite M1 were measured in 92 patients.

RESULTS

The mean concentrations of tramadol during the postsurgery phase were 470+/-323 ng ml-1, 590+/-410 ng ml-1 and 771+/-451 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-), P<0.05); the mean concentrations of the metabolite M1 were 57+/-18 ng ml-1, 84+/-34 ng ml-1 and 96+/-41 ng ml-1 in the (+)-, racemate- and (-)-group, respectively ((+) vs (-) and (+) vs racemate, P<0.05). The mean concentrations of (+)-tramadol and (+)-M1 were lower in the racemate- than in the (+)-group (P<0.05), those of (-)-tramadol and (-)-M1 were lower in the racemate than in the (-)-group (P<0.05). In the racemate group, the mean serum concentrations of (+)-tramadol were higher than those of (-)-tramadol (P<0.05), whereas the mean serum concentrations of (-)-M1 were higher than those of (+)-M1 (P<0. 05).

CONCLUSIONS

The therapeutic serum concentration of tramadol and M1 showed a great variability. The lowest mean concentrations were measured in the (+)-group and the highest in (-)-group. This is in agreement with the clinical finding that (+)-tramadol is a more potent analgesic than (-)-tramadol.

Presence of opioid receptor-like (ORL1) receptor mRNA splice variants in peripheral sensory and sympathetic neuronal ganglia

The expression of ORL1 receptor mRNA splice variants is determined in peripheral sensory and sympathetic ganglia and compared to mRNA expression for the three classic opioid receptor subtypes (mu, delta, and kappa) using the method of reverse transcription-polymerase chain reaction. ORL1, mu, delta and kappa receptor subtype mRNAs are present in human dorsal root ganglia (DRG) and trigeminal ganglia and rat DRG. ORL1, mu and delta receptor subtype mRNAs are present in rat superior cervical ganglia and only ORL1 and delta receptor mRNAs are present in rat lumbar sympathetic ganglia. Both the ORL1 mRNA splice variants are present in sensory and sympathetic ganglia, however, expression of the shorter ORL1 receptor mRNA dominates over expression of the longer splice variant in rat brain and DRG, whereas, expression of the longer splice variant is dominant in sympathetic ganglia.

Multiple splice patterns of cyclic AMP response element-binding protein mRNA in the central nervous system of the rat

The alternative splicing pattern of cyclic AMP response element-binding protein (CREB) in the central nervous system (CNS) of the rat has been investigated by an exon-flanking polymerase chain reaction (PCR) strategy. A series of RT-PCR studies with primer pairs flanking all possible alternative splicing sites (corresponding to a genomic region with at least one full exon and two flanking introns) has revealed multiple splice patterns in nine regions of the rat CNS. These include some novel transcripts that lack the phosphorylation site and a segment of the leucine zipper region which is crucial for dimerization and DNA binding. Some isoforms previously reported as testis-specific were also detected in the rat CNS. The findings from this study, which include differential splicing patterns among CNS regions, suggest a complex expression and functional regulation of CREB in the CNS.

[Anesthesia for cesarean section in Germany. A survey]

AIM OF STUDY

Goal of this survey is to give an overview of anaesthesia for caesarean section in Germany.

METHOD

In 1994 and 1995, we sent a questionnaire to the chief-anaesthetists of all German hospitals with departments of gynaecology/obstetrics to find out the routine anaesthetic procedures for caesarean section.

RESULTS

We obtained data from 409 hospitals (response rate 46.4%) with 321,816 births--50,123 of which were sections (mean caesarean section rate 16.6%). The mean general anaesthesia rate for elective caesarean sections was 66.5%, for non-elective sections 90.8%. The mean epidural anaesthesia rate for caesarean section was 22.6% and the mean spinal anaesthesia rate was 9.8%. For general anaesthesia most hospitals used antacids and/or histamine2-receptor antagonists (64.6% of responding hospitals). Anaesthesia was induced with intravenous barbiturates (82%), succinylcholine for intubation (98.2%) and no opioids before clamping of the cord (94.8%). For regional anaesthesia bupivacaine was the most common local anaesthetic (spinal 84.0%, epidural 96.8%). Opioids were added to local anaesthetics for epidural anaesthesia at 21.4% of the hospitals.

CONCLUSIONS

General anaesthesia is the commonest practice for caesarean sections at German hospitals. Nowadays regional anaesthesia gains more importance compared to previous German surveys and in agreement with foreign data.

5-Hydroxytryptamine receptor subtype messenger RNAs in human dorsal root ganglia: a polymerase chain reaction study

Although serotonin has been shown to play an important role in peripheral pain mechanisms, the specific subtypes of serotonin receptors involved in pain and hyperalgesia remain poorly understood. To date, no previous study has attempted to determine the presence of any serotonin receptor subtype in human dorsal root ganglia. In this study, the presence of messenger RNA for eight human serotonin receptor subtypes in lumbar dorsal root ganglia was detected using the method of polymerase chain reaction. Dorsal root ganglia were excised post mortem from four patients. Oligonucleotide primers were chosen based on unique regions of complimentary DNA sequence for eight cloned human serotonin receptor subtypes (i.e. 5-HT1A, 5-HT1D alpha, 5-HT1D beta, 5-HT1E, 5-HT1F, 5-HT2A, 5-HT2C and 5-HT7). The presence of 5-HT1D alpha, 5-HT1D beta, 5-HT1E, 5-HT1F, 5-HT2A and 5-HT7 receptor subtype messenger RNA was detected in dorsal root ganglia from three of the four subjects. 5-HT1A receptor subtype messenger RNA was detected in one of the four subjects. No 5-HT2C receptor subtype messenger RNA could be detected. Findings from this study may direct further efforts to determine the role of serotonin receptors in the peripheral nervous system.

[The current standing of obstetrical analgesia and anesthesia. A survey of North Rhein-Westfalia]

BACKGROUND

The purpose of this study was to determine obstetrical pain management practices for labour for spontaneous and operative vaginal deliveries since there were no comparative German data available for the past 10 years.

METHODS

A mail survey was sent to the chief anaesthetists of all hospitals in North Rhine-Westfalia designated to have obstetrical beds. The confidential and standardised questionnaire consisted of 24 mainly multiple-choice questions relating to general issues and methods of analgesia and anaesthesia for vaginal deliveries.

RESULTS

In all, 118 completed replies to 258 sent questionnaires were received, giving a response rate of 46%. Among the 118 hospitals there were 79,157 vaginal deliveries annually. All participating hospitals practiced either systemic analgesics/spasmolytics and/or regional-anaesthetic methods (Table 2). Perineal local infiltration (23.7% of vaginal deliveries, in 99% of cases performed by the obstetrician) and epidural analgesia (23.2% of vaginal deliveries, in 81% of cases performed by an anaesthetist) were the commonest regional-anaesthetic methods. Pudendal nerve blocks were performed in 18.5% of vaginal deliveries (Table 1). Of all participating hospitals, 97% provided a 24-h epidural service. The method of epidural anaesthesia was widely homogeneous in all 118 hospitals (Table 3). Other methods of regional analgesia (i.e., epidural infusions or patient-controlled epidural analgesia) were performed only rarely.

CONCLUSIONS

The methods of obstetrical analgesia and anaesthesia are on a high level and show a broad homogeneity in all hospitals. Overall, the results indicate, in comparison to former studies and in common with other countries, steadily increasing use of regional anaesthesia performed by anaesthetists in contrast to decreasing numbers of local infiltrations performed by obstetricians.

[Pain assessment and therapy in bronchial carcinoma]

In the period from 1983-1991 133 patients (102 men, 31 women) with lung cancer were treated in our pain clinic for 8083 days. Pain was associated with tumour infiltration in 86% of patients and related to therapy in 15%. Even in 6 of 8 patients who were admitted with a diagnosis of "postthoracotomy syndrome" and in all 4 patients with "postradiation syndrome" local recurrence was diagnosed during follow-up. All 17 cases of brachial plexus lesions were caused by local tumour spread. Symptomatic treatment according to WHO guidelines resulted in good pain relief in 92% of patients and on 82% of days. The incidence of dyspnea decreased from 51% of the patients to 16%. Strong opioids were used on 56% of treatment days. Parenteral or spinal administration of opioids was necessary on 3% of days only.

A long-term survey of morphine in cancer pain patients

We surveyed 550 cancer patients who experienced pain and were treated with morphine for a total of 22,525 treatment days. Sufficient pain relief was achieved during more than 80% of this time using an average oral morphine dose of 82.4 mg--significantly lower than other studies. The use of this low dose, which was possible due to the concomitant administration of nonopioids and specific coanalgesics in most patients, resulted in a low incidence of side effects. Constipation and nausea/vomiting were the most common of these side effects. Physical dependence posed no practical problem in discontinuation of morphine treatment. Long-term opioid intake and development of tolerance did not appear to be linked; an increase in morphine dosage was most often explained by progression of the terminal disease. Addiction was a negligible problem, with only one observed case.

[Perineal pain and rectal cancer--prevalence in local recurrence]

Between 1983 and 1989, 85 patients with either carcinoma of the rectum or a recurrence of a previously diagnosed rectal tumour (47 women and 38 men aged 20 to 87 years) were treated in our pain clinic. In 50 patients, the reason for referral was perineal pain which had been present for one week to two years (median six months, 25%-percentile six weeks, 75%-percentile six months). In some patients this was considered to be due to scar tissue formation by the referring doctors. The pain was classified somatic, visceral and neuropathic in approximately equal numbers of patients, and about half of them described more than one type of pain. The other 35 patients were suffering from pain at other sites. In 40 out of 50 patients with perineal pain, local tumour recurrence was diagnosed. In 29 patients, pain symptoms began with a median of 5.5 months before the tumour recurrence was diagnosed. In a further seven patients, other types of tumour dissemination in the pelvis were considered to be the cause of the perineal pain. In only three patients no evidence of tumour was found in the pelvis. A non-neoplastic cause of perineal pain could be definitely confirmed in only one patient on post-mortem examination. 35 patients reported no perineal pain on admission, although in 19 cases a local cancer recurrence was found. 13 of these patients suffered from pain in the area of sensory innervation of the lumbosacral plexus. From 16 patients without a diagnosis of local recurrence, only four reported pain in this area.(ABSTRACT TRUNCATED AT 250 WORDS)