[The anesthesiological questionnaire for patients in the outpatient context : Investigations on patient state of health after outpatient operations using the anesthesiological questionnaire for patients]

BACKGROUND

The evaluation of German postanesthesia questionnaires is often restricted to inpatient medical care. The anesthesiological questionnaire for patients (ANP) has previously been validated only after medical care of inpatients. Therefore, the aim of the present study was to evaluate the validity of the ANP in the context of outpatient surgery and anesthesia.

METHODS

Data from 4547 patients (mean age 18-89 years, sex: m/f, 55%/45%), scheduled for ambulatory orthopedic and trauma surgery, were analyzed. All patients received a standard induction of anesthesia with propofol, sufentanil and 4 mg dexamethasone. Maintenance of anesthesia was achieved with a balanced technique comprising volatile anesthesia (either sevoflurane or desflurane) and sufentanil. In addition, patients undergoing operations on the anterior cruciate ligament received a femoral nerve block with 12-15 ml 0.5% ropivacaine. Of the patients 13% remained in hospital overnight as a result of complex operations (combined anterior and posterior cruciate ligament repair, hip arthroscopy and 10% of those undergoing shoulder operations). Before discharge from the recovery room, patients were asked to answer questions with respect to postoperative symptoms 1h after anesthesia (ESNA 19 items), at the time of interview (ABZ 17 items) and about overall patient satisfaction (10 items). These results were matched with the type of procedure and time data from the patient administration system. All data were analyzed descriptively using parametrical tests.

RESULTS

At both time points, pain in the area of the operation was the predominant symptom (ESNA: 77,1%; ABZ: 74,3%). Pain after shoulder arthroscopy was more severe compared to knee arthroscopy, both with and without repair of the anterior cruciate ligament. Most of the adverse symptoms decreased significantly (p ≤ 0.001) with time, demonstrating progressive recovery of the patient. Patient discomfort was more likely to occur in female than in male patients, and female patients were more likely to be dissatisfied with the progress of recovery. The risk of experiencing adverse symptoms after anesthesia was higher for female than for male patients; this was most apparent for feeling cold (odds ratio, OR 4.08) and nausea and vomiting (OR 3.45). Younger patients (18-40 years) were more likely to express discomfort than both groups of older patients (41-60 years and 61-89 years). Accordingly, younger patients had lower satisfaction levels with respect to both anesthesia and overall perioperative care, and the progress of recovery. Postoperative nausea and vomiting (PONV) were linked to younger age, female sex, and longer procedure times (>40 min).

CONCLUSION

The individual analyses delivered plausible results, which support the validity of the ANP. The ANP may also be used for assessment of postoperative discomfort and patient satisfaction in the setting of outpatient surgery. In view of the short time interval between the two measurement points, the ANP for outpatients could in future be reduced to a single postoperative questionnaire.

[Pain therapy care in Germany-Do patients receiving day care differ from those receiving outpatient or inpatient care at the start of treatment? : A further evaluation based on the KEDOQ-pain data set]

The direct comparison of day care pain patients with patients from other treatment sectors with respect to sociodemographic, pain-related and psychological characteristics has not yet been the subject of systematic analyses. The project core documentation and quality assurance in pain therapy (KEDOQ-pain) of the German Pain Society (Deutsche Schmerzgesellschaft e.V.) makes this comparison possible. This second analysis of the available KEDOQ data was intended to show how patients receiving day care treatment can be characterized using the core data set and whether and to what extent they differ from patients receiving outpatient or inpatient treatment. This is a continuation of the first publication, which showed remarkably small differences between outpatients and inpatients but did not include day care patients.The KEDOQ-pain data from 25 centers with a total of 8953 patients were evaluated. Patients had completed the German pain questionnaire (DSF) between January 2012 and March 2017 and received day care (n = 1264), outpatient (n = 4082) or inpatient (n = 3607) pain therapy treatment. Sociodemographic, pain-related and psychometric data of the DSF reported by patients were evaluated as well as physician information on the pain chronification stage and pain localization. The evaluation was descriptive and compared groups using univariate and multivariate procedures.Day care treated patients were significantly younger, had a higher level of education, were more frequently employed, reported higher impairment values and showed a higher severity index according to von Korff than inpatients and outpatients treated for pain. In addition, they described a shorter pain duration as well as worse habitual well-being (Marburg questionnaire on habitual well-being, MFHW). These predictors explained roughly half of the variance in the prediction of the day care treatment setting. The comparison of outpatients and inpatients showed significant group differences for some variables; however, the effects were very small.The evaluations suggest that pain therapy day care facilities treat a special group of pain patients that significantly differ from patients in other treatment sectors. Cautious conclusions are drawn regarding the systematic allocation of patients to care appropriate to their treatment needs.

[Stressors for patients in the intensive care unit : An analysis taking controllability into consideration]

OBJECTIVE

Studies on stress factors for patients in intensive care units (ICU) have so far concentrated on whether certain stressors have occurred or how stressful they were. There are no studies on stress for patients in ICUs that measured both the perception of stress and the chances perceived to control it; however, loss of control can result in long-term psychopathological consequences, such as depression or posttraumatic stress disorder. Therefore, a questionnaire was developed to evaluate the influence of controllability on perception of stress. The aim of this study was to answer the following questions: which situations were experienced as stressful by patients in ICUs, whether patients perceived them as being controllable and whether the experience of stress depended on the controllability? Furthermore, it was examined which stressful situations are specific to ICUs.

MATERIAL AND METHODS

The questionnaire included 18 potentially stressful situations for ICU patients. These situations were assessed with respect to the occurrence, frequency and duration, the impact of stress and the perception of control. In addition, anxiety was assessed using STAI-X1. A total of 198 ICU patients and 100 patients hospitalized in a general surgery ward were interviewed.

RESULTS

Patients in ICUs remembered significantly more stressful situations than those on the normal ward (M ± SD = 10.2 ± 2.7 vs. 6.6 ± 2.0; d = 1.48; p < 0.001) and perceived them as more stressful (mean stress: M ± SD = 3.6 ± 1.5 vs. 2.2 ± 1.3; d = 1.01; p < 0.001). The most stressful situations for ICU patients were fixation of the arms (M ± SD = 7.47 ± 3.27), mechanical ventilation (M ± SD = 7.36 ± 3.29) and endotracheal suctioning (M ± SD = 7.19 ± 2.99). Approximately one third of patients underwent these situations. Situations experienced by more than 90% of ICU patients were evaluated as being the least stressful experiences, including infusion (M ± SD = 2.7 ± 2.7), measuring heart activity (M ± SD = 2.3 ± 2.7), taking blood samples (M ± SD = 2.2 ± 2.7), and temperature control (M ± SD = 0.9 ± 1.7). Controllability experienced by ICU patients negatively correlated with anxiety (r = -0.20, p = 0.004) and mean sensation of stress (r = -0.36; p < 0.001). When comparing stress levels of ICU patients who perceived controllability in a given situation to those who did not, the greatest effects (Cohen's d > 1.4) were observed for the situations presence of a bed barrier (M ± SD = 0.1 ± 0.4 vs. 5.9 ± 2.8), lighting at night (M ± SD = 0.7 ± 1.7 vs. 5.7 ± 3.3), presence of a ventilation tube (M ± SD = 2.5 ± 2.1 vs. 6.7 ± 3.0) and repositioning of the patient (M ± SD = 2.5 ± 2.9 vs. 6.7 ± 2.9).

CONCLUSION

The experience of loss of control seems to negatively modify the impact of stressors. Thus, an increase in aspects of controllability could reduce the burden on patients during intensive care.

[Management of patients with chronic pain in acute and perioperative medicine : An interdisciplinary challenge]

Chronic pain is a frequent comorbidity of patients in hospitals and has an influence on the clinical course and the duration of hospitalization. There is a need to have a better understanding of chronic pain as a comorbidity and it should be considered to a greater extent in understanding diseases, in treatment concepts and hospital structures to ensure a resource-oriented and high-quality care. This begins on admission by identifying pre-existing pain and related risk factors with the medical history and taking these into account in the treatment regimen. A multimodal treatment approach that involves medicinal, educational, psychological and physiotherapeutic expertise is required in these patients. A unimodal approach in the treatment is not effective. A pain physician should be involved in the treatment team as early as possible. Furthermore, psychological joint supervision should be available for these patients as several studies have demonstrated positive perioperative effects of psychological approaches on the treatment in this patient group.

[Pain therapy in Germany - what is the difference between initial outpatient and inpatient treatment? : Assessment based on the KEDOQ pain dataset]

A comparison of chronic pain patients in outpatient and inpatient treatment settings regarding pain-related and psychological characteristics, has not yet been systematically analyzed. The core documentation and quality assurance in pain therapy (KEDOQ-Schmerz) is a quality assurance system for documentation and quality management of pain therapy in different treatment settings. The system was initiated by the German Pain Society. We used KEDOQ-Schmerz data to describe differences between patients being treated in outpatient and inpatient settings with respect to social, pain-related and psychological factors. In total, the set of KEDOQ-Schmerz data analyzed included information from 4705 patients (from 13 clinics) collected between January 2012 and April 2016. Patients received either outpatient (n = 2682) or inpatient (n = 2023) treatment. The data analyzed comprised sociodemographic, pain-related and psychological data collected through the German Pain Questionnaire (DSF) at the beginning of treatment as well as information about pain chronification and pain localization provided by practitioners. The statistical analysis was carried out by descriptive and comparative data analysis using univariate and multivariate statistical methods. Patients with inpatient treatment were significantly older, more often female and more often had multiple pain localizations. They described stronger pain intensity and more frequently had a higher Mainz Pain Staging System (MPSS) score of pain chronification. They described a significantly poorer physical and mental health-related quality of life in the short form (SF-12) health survey, had significantly higher depression, anxiety and stress values (DASS) and a poorer habitual well-being in the Marburg questionnaire on habitual well-being (MFHW). Significant group differences had only small effect sizes. Even though most predictors for the inpatient treatment setting in multivariate analysis were significant, in total they explained less than 5% of the variance. The results indicate that pain therapy in specialized pain settings more and more has to manage patients with higher pain chronification, higher pain-related stress and previous therapy experience. The differences in patient characteristics between treatment settings are mostly clinically unimportant. Differences in clinical features do not declare the allocation to one treatment setting or the other.

[High pain expectation and impairment from pre-existing pain are risk factors for severe postoperative pain : Results of a study using the Lübeck Pain Risk Questionnaire]

BACKGROUND

The intensity of postoperative pain is characterized by large interindividual variability. Furthermore, strong postoperative pain is known to influence physical recovery after surgery. High (preoperative) pain expectation and pre-existing pain, which are associated with pain-related disability (impairing pain) are risk factors for strong postoperative pain. They can be determined with the Lübeck Pain Risk Questionnaire used for the first time in this study. The aim of this study was to explore the hypothesis that patients with a combination of the characteristics (1) preoperative impairing pain and (2) high pain expectation are more likely to have strong postoperative pain. Patients with these characteristics represent a unique group of patients and are more likely to develop distinct postoperative pain and can therefore be characterized as a risk group.

MATERIAL AND METHODS

A total of 501 patients at the departments of general surgery, plastic surgery, trauma surgery and orthopedic surgery of the UKSH Campus Lübeck were included in this study. All underwent elective surgery. Study patients were 18 years and older. Those needing postoperative treatment in an intensive care unit were excluded from this study (n = 18). The characteristics "preoperative pain" and "pain expectation" were measured with the Lübeck Pain Risk Questionnaire the day before surgery. The primary outcome variable was the average postoperative pain intensity, which was measured with a numeric rating scale (NRS 0-10) and scores > 4 were defined as severe pain.

RESULTS

The NRS range for "preoperative pain" was subdivided as follows: "no pain" (NRS = 0), "functional pain" (NRS = 1-3), and "impairing pain" (NRS = 4-10); that for "pain expectation" as: "low expectation" (NRS = 0-4) and "high expectation" (NRS = 5-10). To determine these cut-off points, they were varied from > 1 to > 8 and those with highest effect size for strong postoperative pain were chosen. Patients with a high pain expectation had significantly stronger postoperative pain (p < 0.001) and significantly more often higher pain intensity than patients with a low expectation (53.3% vs. 20.6%, respectively, p < 0.001). Patients with pre-existing impairing pain had significantly stronger and more frequently higher postoperative pain than patients with pre-existing functional pain (43.4% vs. 18.4%, p < 0.05). Patients with a combination of the factors "preoperative impairing pain" and "high pain expectation" showed distinct postoperative pain with NRS > 4 significantly more often (59.4%, p < 0.001). These findings could be demonstrated for the departments general surgery, plastic surgery and trauma surgery.

CONCLUSION

The combination of both risk factors results in a unique risk group for the appearance of strong postoperative pain. This group can be economically determined in the daily clinical routine using the Lübeck Pain Risk Questionnaire. Further studies must be carried out to show if additional perioperative procedures can be profitable for the risk group identified with the Lübeck Pain Risk Questionnaire; however, patients falling outside the risk group must not be neglected because they too can develop severe postoperative pain.

[Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain]

BACKGROUND

The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013.

METHODS

The guidelines were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain.

RESULTS

Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality).

CONCLUSION

Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.

[Postoperative complaints : gender differences in expectations, prevalence and appraisal]

OBJECTIVE

Women report more severe postoperative complaints than men (e.g. nausea and pain) and expectations of complaints prior to surgery influence the postoperative complaints. Therefore, the aim of this study was to explore if gender differences in complaint expectation can account for differences in postoperative complaints. A further objective was to investigate the effective load of complaints and to look for gender differences.

METHODS

In total 281 patients (128 men and 153 women) were included in the study and all patients underwent elective general surgery. Patients were asked for symptom expectations and symptom experiences prior to surgery. After surgery they answered the Anesthesiological Questionnaire (ANP) a validated self-rating method for the assessment of postoperative symptoms and complaints. The symptoms referred to in the questionnaire included sensation of cold, sensation of heat, nausea and vomiting, tickly throat, croakiness, dry mouth and thirst, difficulty in breathing, sore throat, pain in the area of surgery, pain in the area of infusion, muscle pain, back pain, headache, difficulties in urination, difficulty in awakening and feeling of somatic discomfort. In addition patients rated the affective load of the postoperative complaints.

RESULTS

In previous surgery women reported experiencing more postoperative somatic complaints than men. Sex-related differences were significant (p < 0.05) for sensation of cold, nausea and vomiting, tickly throat, croakiness, sore throat, pain and the feeling of somatic discomfort. Likewise, women expected more intensive postoperative complaints following the forthcoming operation. After surgery women reported significantly more severe complaints in negative symptoms of the ANP (e.g. nausea and vomiting, pain and somatic discomfort). Effect sizes of sex-related differences varied according to the symptom (e.g. for pain effect strength d = 0.50, for nausea d = 0.60 and for thirst d = 0.13). Effect sizes decreased when the effect of expectation was statistically controlled. Logistic regression revealed that expectation was an independent predictor for the sensation of severe nausea (odds ratio OR 4.3] and intensive postoperative pain (OR 2.6). Regardless of gender, postoperative pain, nausea and dry mouth/thirst were symptoms with the highest affective load.

CONCLUSIONS

Preoperative expectations increase gender differences in somatic complaints following surgery. Anesthesiological education of patients should influence dysfunctional expectations. Postoperative pain, nausea and thirst should be the main targets of interventions to improve patient complaints.

[Success of treatment in higher stages of pain chronification as well? An evaluation of the Mainz pain staging system based on the QUAST-analysis sample]

BACKGROUND

More than 10 years ago Gerbershagen gave a pessimistic prognosis for treatment success in patients with higher stages of pain chronification. To date only few studies concerning this statement exist and the results are inconsistent. The objective of this study was to evaluate the prognostic validity of the Mainz pain staging system (MPSS) in a large multicenter sample. It was assessed whether effects of treatment in patients with higher stages of pain chronification are less than those in other patients. Of further interest was whether treatment success is related to different outcome measures.

METHODS

A total of 1,461 patients with the pain syndromes headache, neuropathic pain, back pain or algiomuscular pain and arthralgia were enrolled in the analysis. They were selected from the QUAST analysis sample which includes patients from 19 cooperating pain clinics. All patients had completed the German pain questionnaire prior to pain treatment and these data were compared with the last available questionnaire during the course of treatment. Outcome measures were pain intensity, psychological disability scores and patient global impression of success (PGIS).

RESULTS

Analysis showed a significant improvement of all outcome measures in every MPSS stage. The greatest improvement was noted for pain intensity whereas outcome variables regarding mental health revealed the lowest improvement. Compared with patients with low pain chronification, changes in pain intensity were smaller for patients with the highest MPSS stage III but even in these patients the strength of effect was more than 0.80. About 50% of all patients showed a reduction of pain intensity of 2 or more points on an 11 point numerical rating scale and 46.6% of patients with a MPSS stage III showed this improvement. Importantly, PGIS was independent of the stage of chronification. Nearly 45% of all patients evaluated the treatment success as good or very good.

CONCLUSIONS

According to the view of the patients, treatment in specialized pain centres is successful even in the highest stage of pain chronification. This notwithstanding, success of treatment must not be confounded with the efficacy of an intervention. It has to be noted that the results of the current study do not allow conclusions regarding efficacy of treatment.

[Characterization of chronic pain patients in German pain centers : core data from more than 10,000 patients]

BACKGROUND

In 1998 the board of the DGSS introduced a computerized documentation system named QUAST (quality assurance in pain therapy) building the foundation for a large, anonymous database that served as a data source for the statistical characterization of clinically relevant profiles of patients in German pain clinics.

METHODS

A total of 10,054 data files collected between 1998 and 2004, including socio-demographic as well as psychometric and pain parameters were analyzed.

RESULTS

The main pain diagnoses found in the database sample were back pain (37%), neuropathic pain (21.4%), soft tissue or arthralgia pain (19.5%) and headache (10.6%). The average duration of illness upon presentation at pain clinics was 7 years, nearly 20% contacted it within the first year. Of the sample, 43.8% of the patients were in the second chronicity stage and 39.0% in the third stage of the Mainz Pain Staging System (MPSS). Psychological measurements concerning despression, pain disability and quality of life indicated a great amount of psychological distress. Pronounced differences between main diagnostic groups were observed not only for psychological factors but also for direct pain parameters.

CONCLUSIONS

The documented data differ from other population-based data collections. In contrast to common belief there are a considerable number of patients who find access to specialized pain therapy institutions at an early stage of their illness. The hitherto regular use of generic, syndrome-overlapping diagnosis and treatment tools should be reconsidered taking into account the differences found between the main pain diagnosis groups. Lastly, this analysis provides current data on the psychological state of chronic pain patients showing a high degree of psychological distress and underlying the need of psychotherapeutic interventions in the treatment of chronic pain patients.

[Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): diagnosis of postoperative delirium in cardiac surgery]

OBJECTIVE

Since 2001 the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), a method for the diagnosis of delirium, has been available for the Anglo American area which can also be applied to mechanically ventilated patients. This study was conducted to answer the following questions: 1. Can a German version of the CAM-ICU be applied to patients after cardiac surgery? 2. What is the prevalence rate of postoperative delirium after cardiac surgery diagnosed by the CAM-ICU? 3. Do patients with and without the diagnosis delirium differ in the clinical variables usually associated with this disorder in cardiac surgery?

METHODS

A total of 194 patients undergoing cardiac surgery served as the analysis sample (85.5% of the total group). The CAM-ICU was carried out every day for 5 days after the operation. Sociodemographic and clinical variables were collected to examine the validity of CAM-ICU. Postoperative complaints were assessed by the Anaesthesiological Questionnaire for Patients (ANP).

RESULTS

Postoperatively, the CAM-ICU could be applied to almost all patients without any problems. The prevalence rate of delirium was 28.4% and 85.5% of the delirium diagnosed was a hypoactive subtype when diagnosed for the first time. Patients with delirium diagnosed by CAM-ICU were older (p<0.001), had a lower educational level (p<0.05), longer anaesthesia time and operation time (p<0.05), a longer postoperative ICU stay (p<0.001), were mechanically ventilated for a longer time postoperatively (p<0.001), more often reintubated (p<0.01) and had higher leucocytes postoperatively (p<0.10). More patients with delirium had the lowest postoperatively measured oxygen saturation below 95% (p<0.01).

CONCLUSION

The CAM-ICU is an economic method for the assessment of delirium which can easily be learned. It can be applied to patients after cardiac surgery without any problems.

Patient Mood and Neuropsychological Outcome After Laparoscopic and Conventional Colectomy

The study was designed to compare patients after laparoscopic and conventional colectomy with regard to early postoperative mood, cognitive function, and neurocognitive variables S100β and neuron-specific enolase (NSE). Forty-five laparoscopic and 25 open colectomies were enrolled into the prospective study. Outcome measurements were positive and negative postoperative mood (BSKE), neuropsychological tests (Trail-Making Test; word reproduction; Stroop Test), and serum biochemical parameters (S100β; NSE). Following laparoscopic procedure, patients described significantly better positive mood ( P < .05), tended to require less time in the Trail-Making Test and Stroop Test, and had lower postoperative serum concentrations of S100β compared to conventional colectomy patients ( P < .01). The current results revealed several group differences, which, in their entirety, seem to represent a more beneficial outcome after laparoscopic colonic surgery.

Einfluss negativer Stressverarbeitung auf postoperatives Schmerzerleben und -verhalten

OBJECTIVE

The aim of the study is to show whether negative coping style has an impact on post-operative pain reporting and pain-related behaviour.

METHODS

After informed consent 48 gynaecological patients were enrolled in the study. Negative coping style was assessed by using the stress coping questionnaire SVF-78 (Janke and Erdmann). Patients were dichotomised by scores of the negative coping style. Pain reporting concerned pain intensity and pain quality. Pain-related behaviour was assessed by patient-controlled analgesia (PCA). Pain intensity and pain quality were assessed prior to surgery and 24 h after surgery. Patient-controlled analgesia was recorded up to 24 h after surgery. Trait anxiety (STAI-X2) was used as a control variable.

RESULTS

Patients with high scores in negative coping style report increased levels of pain in both affective and sensory pain perception. At the same time patient-controlled analgesia is used less frequently by this group. This result remains significant considering trait anxiety as a covariate.

CONCLUSIONS

High negative coping style may cause a discrepancy between pain reporting and pain-related behaviour. This should be taken into account in the perioperative care of patients.

Die Anwendung der Spiral-Larynxmaske zur Adenotomie bei Kindern - Ein retrospektiver Vergleich zur Intubationsnarkose

BACKGROUND

While adenoidectomy in childhood is a standard procedure, different alternatives of airway and anaesthesiologic management are discussed. Therefore we investigated retrospectively paediatric anaesthesias with laryngeal mask (LMA) or endotracheal intubation (ITN) during adenoidectomies in our department of otorhinolaryngology.

METHODS

A retrospective analysis of 385 anaesthesia records of the last three years was performed. Variables were age and weight of the children, anaesthetics, surgical procedures, size of LMA, recovery time, anaesthesiological complications as well as the incidence of abandoning the laryngeal mask in favour of a tracheal intubation.

RESULTS

Recovery time was significantly reduced (3.63 min) in LMA group compared to ITN group (p < 0.001). Complications did not arise more frequently in the LMA group. LMA had to be changed into ITN in 11 cases (5,6 %) only.

CONCLUSION

Our study shows the LMA being a safe and effective alternative to ITN in airway treatment of children undergoing adenoidectomy.

Diabetes Mellitus Increases Adverse Neurocognitive Outcome after Coronary Artery Bypass Grafting Surgery

BACKGROUND

Cognitive dysfunction is a well known problem in the postoperative period in cardiac surgery. We hypothesised that the incidence of postoperative cognitive dysfunction in patients with diabetes mellitus is higher than in the nondiabetic patient.

METHODS

Thirty-four patients (11 females, 23 males) with a mean age of 62.44 +/- 7.52 undergoing on-pump CABG surgery were studied in a prospective manner. Fourteen patients had treated diabetes mellitus (Group I) and 20 were nondiabetic (Group II). All patients were operated upon by the same surgeon under standardised intra- and perioperative conditions. Patients with preoperative dementia (MMSE < 24) or advanced cerebrovascular disease were excluded. An extensive set of tests examining emotional and cognitive state, stress-coping and quality of life were performed preoperatively. Emotional and cognitive variables were assessed daily from day two to five postoperatively.

RESULTS

All tests showed comparable results between the groups preoperatively. The perfusion lasted considerably longer in Group I (102.5 +/- 16.61 vs. 83.9 +/- 14.1 min) as did the cross clamping (64.21 +/- 18.31 vs. 51.75 +/- 10.88 min). Postoperative cognitive outcome was significantly worse in Group I with regard to the Stroop Test (29.46 +/- 8.6 vs. 24.01 +/- 6.23, P = 0.02), the Abbreviated Mental Test (8.04 +/- 0.71 vs. 8.68 +/- 0.78, P = 0.02) and the Trial Making Test (35.72 +/- 11.38 vs. 29.3 +/- 7.77 P = 0.04). These differences persisted even after adjustment for perfusion- and cross-clamping time.

CONCLUSION

The cognitive outcome in the early postoperative period is worse in diabetic patients compared to nondiabetics. Speed-related cognitive functions are mainly affected. Probably, this reflects a different physiology of cerebral perfusion during extracorporeal circulation. Optimising perfusion strategies to improve the outcome of diabetic patients should be the next topic of study.

Quality of life in elderly men with androgen deficiency

The partial androgen deficiency in aging male (PADAM) has been of great interest to investigators and the public in the last few years. For males, androgens are said to be essential for the maintenance of quality of life (QoL) but there are no data available with respect to QoL and PADAM yet. In order to evaluate changes of individual well-being of males older than 50 years and with subnormal levels of free testosterone (FT) (<200 pmol l(-1)), these men were asked to fill in a questionnaire regarding QoL. The objective of this study was to compare age-matched males with androgen deficiency (group 1; n = 24) and normoandrogenic elderly men (group 2; n = 24) with respect to QoL and somatic indicators of the endocrine status. Participants suffered from benign prostatic hyperplasia (BPH) and were hospitalized for prostate surgery. Health-related QoL was assessed by the SF-12 Health Survey, including the physical health index and the mental health index. The SF-12 was enlarged by the scales 'vitality' and 'psychological well-being' of the SF-36. Additionally, patients were asked about social and clinical items. There were no statistically significant differences between the two groups regarding social and clinical parameters. The physical health index was reduced in group 1 (P < 0.05; effect size was medium (d = 0.57)) whereas the mental health index was similar in both groups. The correlation between the two health indices was very low and not statistically significant (r = 0.05, P = 0.72). Patients of group 1 described a lower vitality compared to group 2 (P < 0.05), but no differences could be observed regarding psychological well-being. Therefore, androgen-deficient patients seem to have the impression of a reduced physical ability. Our data emphasize that the subjective description of health-related aspects of QoL is a very sensitive methodological approach to discover psychological differences between patients. For the differentiation between androgen-deficient patients and those with normal testosterone levels the physical health index seems to be more sensitive than the mental health index. A question of interest is whether this difference remains detectable if testosterone is supplemented to androgen-deficient men. Whether testosterone supplementation is beneficial to these patients has to be carefully considered.

Psychologische Persönlichkeitsmerkmale, Operationsverlauf und Genesung bei Patienten mit Präferenz für Allgemein- oder Lokalanästhesie

OBJECTIVE

This study addresses two questions concerning open inguinal hernia repair patients: (1) are there differences in psychological traits between patients opting for local vs. general anaesthesia and (2) assuming comparable operations, are there any differences between the two groups during surgery and postoperative recovery?

METHODS

A total of 69 male patients aged between 18 and 80 took part in the study. After having been briefed about anaesthesia, they opted for either local (n=40) or general anaesthesia (n=29). In order to determine psychological traits, patients filled out questionnaires before the operation [NEO Five-Factor-Inventory (NEO-FFI) and the Stress Coping Questionnaire (SVF)] and the Anaesthesiological Questionnaire (ANP) after the operation. Data about the surgery (duration of anaesthesia and operation, blood pressure and heart rate) and the convalescence period (time spent in recovery room, length of stay in hospital) were also recorded. The patients' information processing skills were measured preoperatively and postoperatively using the "Trail Making Test".

RESULTS

Patients preferring local anaesthesia were significantly older than those who chose general anaesthesia. Therefore two similar age groups were formed by using the method of matched samples (n=2x26). Between these groups no significant differences were found with reference to psychological traits, but markedly extraverted patients favoured local anaesthesia. There were no differences in the duration of anaesthesia and surgery. Local anaesthesia patients spent less time in the recovery room and in hospital than general anaesthesia patients. Postoperatively, the cognitive state and the satisfaction with the anaesthesia were comparable between both groups.

CONCLUSION

Psychological traits do not have a significant impact on the choice of either local or general anaesthesia. However, highly extraverted patients prefer local anaesthesia while extreme introverts prefer general anaesthesia. Our findings suggest that local anaesthesia will become more widely adopted for the repair of groin hernia. Future studies should focus on optimising the perioperative care for patients who choose local anaesthesia.

[The Anaesthesiological Questionnaire for patients in cardiac anaesthesia. Results of a multicenter survey by the scientific working group for cardiac anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine]

OBJECTIVE

The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire was adapted for use in cardiac anaesthesia (ANP-KA). The study was conducted to show the value of ANP-KA as a practicable means of assessing the patient's state after cardiac anaesthesia and for its use in quality assurance.

METHODS

A total of 1,688 patients from 19 clinics were included who had exclusively received heart valve surgery, CABG surgery or both operations. They completed the ANP-KA between days 1 and 8 postoperatively.

RESULTS

The ANP-KA was completed by 79.1% of the patients without any assistance. The highest incidence rates were reported for a dry mouth/thirst (85.1%) and for pain in the area of surgery (60.2%). Plausible and significant differences in patients' symptoms between the grading for the immediate postoperative period and the current state at filling in the questionnaire were found. Women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with anaesthesiological care and convalescence. More complaints were reported after heart valve surgery than after CABG and satisfaction with convalescence was significantly lower after heart valve surgery. The clinics differed with respect to the reported somatic complaints and satisfaction scales.

CONCLUSION

The results demonstrate the practicability and validity of the ANP-KA for the assessment of postoperative complaints and patient satisfaction after cardiac surgery.

[Reduction of chronic pain for non-postherpetic peripheral neuropathies after topical treatment with a lidocaine patch]

INTRODUCTION

To clarify whether the therapeutic indication for a lidocaine patch to treat postherpetic neuralgia can be extended to include other focal peripheral neuropathic pain syndromes, we performed a subgroup analysis of a placebo-controlled, double-blind randomized study.

METHODS

The study included 16 patients with focal peripheral painful neuropathies of non-herpetic origin, pain intensity > or =40 mm (VAS), and a stable pain medication. The patients received either the lidocaine patch 5% for 1 week or a placebo patch for 12 h daily according to a crossover design. Persistent pain, mechanical allodynia, and adverse events were assessed daily by the patients. Additionally, the pain perception test, the list of physical complaints, the depression test, and the health-related quality of life (SF-36) were used. Of the enrolled patients, 12 were statistically analyzed.

RESULTS

Persistent pain was reduced by the lidocaine patch almost significantly and allodynia was reduced significantly in comparison to the placebo patch. Scores for physical complaints improved significantly with the lidocaine patch. Only mild focal skin irritations occurred.

CONCLUSIONS

As an adjuvant medication, the lidocaine patch is effective and safe for reducing chronic pain and physical complaints in focal non-herpetic neuropathies.

Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial

BACKGROUND AND OBJECTIVE

Remifentanil has unique pharmacokinetics that might allow faster recovery after neurosurgery. We investigated the effects of a propofol/sufentanil versus a remifentanil/propofol regimen on the primary end-point tracheal extubation time.

METHODS

In the Neurosurgery Department of a University Hospital, 36 patients awaiting craniotomy for supratentorial tumour resection were randomly assigned to one of two study groups. In the sufentanil/propofol group, anaesthesia was induced with 0.5 microg kg(-1) sufentanil and 1-2 mg kg(-1) propofol. Propofol infusion and boluses of sufentanil were administered for maintenance. In the remifentanil/propofol group, anaesthesia was started with an infusion of remifentanil (0.2-0.35 microg kg(-1) min(-1)) and a bolus of propofol (1.5-2 mg kg(-1)). Patients received a propofol infusion and a remifentanil infusion for maintenance of anaesthesia. Recovery times were taken from cessation of the propofol infusion. In addition, data about self-reported nausea and vomiting, pain and analgesic requirements were collected.

RESULTS

Patients in the remifentanil/propofol group were extubated earlier (mean times 6.4 (+/- SD 4.7) versus 14.3 (+/- 9.2) min; P = 0.003). The two groups were similar with respect to postoperative nausea and vomiting, and patient-reported pain scores. Fifty per cent of the remifentanil/propofol patients and 88% of the sufentanil/propofol patients required no analgesics within 1 h after operation (P = 0.03).

CONCLUSIONS

The remifentanil/propofol regimen provided quicker recovery. The two regimens were similar in terms of postoperative nausea and vomiting and patient-reported pain scores, but patients in the remifentanil/ propofol group required more analgesics within 1 h postoperatively.

[Validation of the German Mainz Pain Staging System in different pain syndromes]

OBJECTIVE

Our study was carried out to clarify whether differences in pain intensity,pain-related disability,depression and quality of life change with respect to the stage of chronicity of the Mainz Pain Staging Study (MPSS) in different pain syndromes. Keywords.

METHODS

All patients with an initial pain clinic consultation from July 2000 to July 2001 and suffering from four major pain syndromes ("headache", "neuropathic pain", "back pain" or "muscle and joint pain") were included. Indicators of validity were several self-rating scales from the German pain questionnaire of the German Chapter of the International Association for the Study of Pain (DGSS). Patient data were collected using QUAST, a database environment specifically developed for documentation and quality assurance in pain therapy. An assessment was made for each of the four major diagnoses to determine whether patients in the three chronicity stages differed in their psychometric test results. In addition,the four diagnosis groups were tested for differences from one another.

RESULTS

A total of 862 patient charts with documented pain syndromes and MPSS were extracted and analyzed. The extent of the subjective psychosocial stress and disability increased in all diagnosis groups and was correlated with the chronicity stage. The proportion of patients with an indication of clinically relevant depression (ADS score >23) increased with chronicity regardless of the pain diagnosis. The four main diagnosis groups differed with respect to the chronicity stage according to MPSS (P<0.001), with headache patients being classified predominantly as stage I. Patients with an additional pain diagnosis had a higher chronicity stage (P<0.001).

CONCLUSION

Our results underline the validity of the MPSS for the four diagnosis groups examined; however, pain diagnosis must be controlled in all studies using chronicity stage as an independent variable, e.g., therapy studies. For optimal results physicians must closely follow the test instructions of the MPSS.

Increased frequency of X-bearing sperm in males from an infertility clinic: analysis by two-color fluorescence in situ hybridization

Semen samples from 34 men visiting the Lübeck infertility clinic were investigated using a two-color FISH method to determine the ratio of X- and Y-bearing sperm. The overall ratio was significantly shifted to a preponderance of X-containing sperm. A statistical comparison with seven reports from the literature which included 53 normal probands demonstrated in our patients a significant tendency of a preponderance of X-bearing sperm and significantly less Y-bearing sperm. Furthermore, the Lübeck sperm samples are remarkably more heterogeneous in respect to their variability of X- and Y-bearing spermatozoa than in the other mentioned studies with normal probands. These phenomena have to be evaluated in further studies on groups of infertile males showing similar infertility histories.

[Reliability and validity of the Anaesthesiological Questionnaire for electively operated patients]

OBJECTIVE

The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire consists of two parts. Part 1 assesses the intensity of symptoms regarding the postoperative period in the "recovery-room and the first hours on the ward" (19 items) and the "current state" (17 items). Part 2 assesses patient satisfaction with the anaesthetic care as well as the unspecific perioperative care and postoperative convalescence. The questionnaire was designed to fulfill the criteria of reliability and validity and to serve as a practicable means of auditing the quality of routine clinical practice.

METHODS

A total of 1,112 patients older than 18 years completed the questionnaire after an elective operation. Additionally data concerning the type of anaesthesia were recorded from the anaesthesia chart. To determine retest-reliability, 94 patients competed the ANP twice postoperatively.

RESULTS

The participants of the survey represented 74.6% of the total collective. Out of 19 items 16 had a retest-reliability of r(tt)>0.70, the 3 other items had a reliability of r(tt)>0.50. Reliability (Cronbach's Alpha) of the patient satisfaction scales was between r(tt)=0.76 and r(tt)=0.91. In relation to the period immediately after anaesthesia,women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with perioperative care. Younger patients (18-49 years old) described more postoperative complaints than older patients and a lesser degree of satisfaction with perioperative care. There were plausible differences in postoperative complaints between patients who received general vs. regional anaesthesia. Patients reported less postoperative complaints after TIVA than after volatile anaesthetics. The configuration of patient characteristics and anaesthesia gives indications to "risk groups" who predominantly suffer after anaesthesia.

CONCLUSIONS

The Anaesthesiological Questionnaire (ANP) is a reliable and valid method for the assessment of postoperative complaints and patient satisfaction.

Remifentanil-clonidine-propofol versus sufentanil-propofol anesthesia for coronary artery bypass surgery

OBJECTIVE

To compare a remifentanil-clonidine-propofol regimen with conventional sufentanil-propofol anesthesia.

DESIGN

Randomized, nonblinded trial.

SETTING

A single university hospital.

PARTICIPANTS

Male patients scheduled for coronary artery bypass graft (CABG) surgery.

INTERVENTIONS

In the control group, anesthesia was induced with 0.5 microg/kg of sufentanil and 0.2 to 0.3 mg/kg of etomidate after preoxygenation. Propofol (50 to 100 microg/kg/min) and sufentanil (0.5 to 1.0 microg/kg/h) were started after endotracheal intubation. Sufentanil was stopped after aortic decannulation. In the remifentanil-clonidine group, anesthesia was started with remifentanil (0.15 to 0.3 microg/kg/min), followed by etomidate (0.2 to 0.3 mg/kg). Propofol was started at 50 to 100 microg/kg/min, and after endotracheal intubation, clonidine infusion was started (6 to 20 microg/h). Patients received piritramide (0.15 mg/kg) and metamizole (20 mg/kg) for transitional analgesia. In both groups, propofol infusion was reduced to 30 to 60 microg/kg/min at skin closure and stopped when assisted spontaneous breathing led to adequate gas exchange.

MEASUREMENTS AND MAIN RESULTS

The main outcomes were recovery times; somatic variables; plasma catecholamine levels; and self-recorded pain, nausea, and vomiting. Patients in the remifentanil-clonidine group were extubated earlier and had lower plasma epinephrine and norepinephrine levels. After transitional analgesia, the remifentanil-clonidine patients had similar postoperative analgesic use and self-reported pain and side-effect scores.

CONCLUSION

Compared with a sufentanil-propofol regimen, an anesthetic regimen for CABG surgery that combines remifentanil, clonidine, and propofol provides similar hemodynamics. The remifentanil-clonidine regimen reduces catecholamine levels and hastens recovery from anesthesia.

[Quality of life after aortic valve replacement. Self-management or conventional anticoagulation therapy after mechanical valve replacement plus pulmonary autograft]

BACKGROUND

The improvement of quality of life gains increasing importance for the judgement of operative techniques. Besides the commonly used mechanical substitutes or bioprostheses for aortic valve replacement, the interest in the Ross procedure is growing. The aim of the study was to compare the quality of life after the Ross procedure with that after mechanical aortic valve replacement with two different anticoagulation regimes (self-management or conventional therapy).

METHODS AND RESULTS

Clinical, echocardiographic and quality of life investigations (SF-36) were performed in patients with mechanical aortic valve replacement and self-management of anticoagulation (group A, n = 20) or conventional anticoagulation therapy (group B, n = 20) and in patients after the Ross procedure (group C, n = 20). The mean ages were 59.5 +/- 9.2 (group A), 61.2 +/- 8.1 (group B) and 59.3 +/- 9 years (group C). Significantly lower values of quality of life (SF-36) were observed in group B compared with group A (5 of 9 subtests) and with group C (6 of 9 subtests) and also in the physical and mental health sum scales.

CONCLUSION

In this study the quality of life in patients after the Ross procedure and similarly after mechanical valve replacement and self-management of anticoagulation is superior to the quality of life after mechanical valve replacement and conventional anticoagulation.

[Comparison of severity of chronic pain in patients differing in pain diagnosis: an analysis by means of the Mainz Pain Staging System]

INTRODUCTION

Testing the validity of the Mainz Pain Staging System (MPSS) is often carried out by pain classification according to chronic stage. It is assumed that pain syndromes distribute equally over the chronic stages. This analysis was carried out to answer three questions: Do different pain syndromes vary in chronicity, do the four axes of the MPSS differ between pain syndromes, and are there any specific item responses with respect to a pain syndrome?

METHODS

406 patients with different pain diagnoses were included in this analysis. Patients were chosen from the PAIN-Documentation-System of the pain outpatients' department of the Medical University of Luebeck. The pain score according to MPSS had been assessed, and a diagnosis attributed according to the Multidimensional Classification of Pain (MASK).

RESULTS

Pain diagnoses do differ in pain chronification. Patients with headache showing the lowest chronification, and patients with back pain describing the most severe chronification, formed the extreme patient groups. Further analysis using the axes of the MPSS demonstrate different sensitivity with respect to pain syndromes, i. e. intake of drugs being the least sensitive and aspects of time being the most sensitive axes. Statistical analysis using configural frequency analysis indicated a relation between pain syndromes and specific item responses.

CONCLUSION

Using pain stages of the MPSS as an experimental factor in studies of pain, it is imperative either to control pain syndromes or to confine to a single pain syndrome, to avoid confusion between pain syndromes and severity of pain chronification.

Quality of life in aortic valve replacement: pulmonary autografts versus mechanical prostheses

OBJECTIVES

We sought to determine whether the quality of life (QoL) is different in patients after aortic valve replacement with mechanical prostheses or pulmonary autografts.

BACKGROUND

Quality of life after mechanical valve replacement may be affected by the risk of thromboembolism and anticoagulation, and after autograft implantation, by the risk of degeneration and re-operation especially of the homograft.

METHODS

Two groups of 40 patients each--one after the autograft procedure (group I) and one after mechanical valve implantation (group II)--were matched for age, gender and length of follow-up. At latest follow-up, all patients underwent routine echocardiography, the short-form health survey (SF-36) QoL survey and an extensive psychological investigation.

RESULTS

Patients with an autograft showed better QoL scales, as compared with mechanical valve recipients. The difference was significant for both the physical (72.72+/-20.00 vs. 60.27+/-26.07, p = 0.021) and psychological health sum scores (74.71+/-21.03 vs. 64.71+/-23.49, p = 0.046) and for the subtests of physical functioning (73.72+/-22.44 vs. 62.77+/-25.42, p = 0.049), physical pain (88.39+/-19.13 vs. 73.36+/-27.08, p < or = 0.006), general health perception (64.37+/-17.88 vs. 51.86+/-22.86, p < or = 0.008) and health change (61.89+/-18.94 vs. 50.11+/-24.37, p = 0.02). The QoL variables did not correlate to pressure gradients, ejection fraction and New York Heart Association functional class. Psychometric tests revealed no meaningful differences between the groups.

CONCLUSIONS

This study provides some evidence that patients with pulmonary autografts have greater benefit in terms of QoL, as compared with recipients of mechanical valve substitutes.

Emergency medical service transport-induced stress? An experimental approach with healthy volunteers

This randomized controlled trial was designed to evaluate the effects of simulated emergency medical service (EMS) transport related stress on hemodynamic variables, and catecholamine plasma levels. A total of 32 healthy male volunteers were randomized to being carried by paramedics from a third-floor apartment through a staircase with subsequent high-speed EMS transport with lights and sirens (stress; n = 16); or sitting on a chair for 5 min, and lying on a stretcher for 15 min (control; n = 16). Blood samples and hemodynamic variables were taken in the apartment before transfer, at the ground floor, and at the end of EMS transport in the stress group, and at corresponding time points in the control group. The stress versus control group had both significantly (P < 0.05) higher mean +/- SEM epinephrine (71 +/- 7 versus 37 +/- 3 pg/ml), and norepinephrine (397 +/- 29 versus 299 +/- 28 pg/ml) plasma levels after transport through the staircase. After EMS transport, the stress versus control group had significantly higher epinephrine (48 +/-6 versus 32 +/- 2 pg/ml), but not norepinephrine (214 +/- 20 versus 264 +/- 31 pg/ml) plasma levels. Heart rate increased significantly from 72 +/- 2 to 84 +/- 3 bpm after staircase transport, but not during and after EMS transport. In conclusion, volunteers being carried by paramedics through a staircase had a significant discharge of both epinephrine and norepinephrine resulting in increased heart rate, but only elevated epinephrine plasma levels during EMS transport. Transport through a staircase may reflect more stress than emergency EMS transport.

Zolpidem and promethazine in pre-anaesthetic medication. A pharmacopsychological approach

This study dealt with the question: What are the effects of different doses of the benzodiazepine-like agent zolpidem and the phenothiazine derivative promethazine on mood in pre-anaesthetic medication? Subjects were 192 female and male patients awaiting elective surgery. Two drugs were administered to the patients in the evening before anaesthesia according to a 3 x 2 factorial randomized double-blind design. The first drug factor was zolpidem (8.03 vs. 16.06 mg) versus placebo. These drugs were combined with the second drug factor, either promethazine (50 mg) or placebo. In summary, the results confirm the hypothesis that zolpidem 8.03 mg can induce paradoxical effects, especially of anxiety, 1 h after application. When the dosage is doubled, no adverse effects are found, but there are no effects different from placebo either. Men could probably be described as a risk population for the adverse effects of zolpidem 8.03 mg. Furthermore, selective deactivating effects of promethazine 50 mg were shown in this study. In addition to these anaesthesiological aspects, this study showed promethazine to be useful as a research tool, suitable as a reference drug to detect deactivating effects. The multidimensional self-report inventory BSKE(EWL) (Befindlichkeitsskalierung durch Kategorien und Eigenschaftswörter) detected the expected drug effects, indicating that this instrument is suitable for further pharmacopsychological research.

[Rating the perioperative period by patients. First evaluation of a new questionnaire]

OBJECTIVE

There is an increasing demand for internal clinical quality assurance. For this reason methods for the assessment of patients' satisfaction and postoperative symptoms and complaints are needed. This article describes a new questionnaire for the measurement of these aspects.

METHODS

The questionnaire consists of two parts. Part 1 assesses the intensity of symptoms related to the postoperative periods "recovery room", "first hours on ward" and "current state". Part 2 measures patients' satisfaction with anesthesiological care, unspecific perioperative care and postoperative convalescence. 431 patients completed the questionnaire after an elective operation.

RESULTS

Results demonstrate a plausible difference in patients' symptoms between the three postoperative periods. The difference between the remembered complaints in the "recovery room" and the "first hours on ward" is of small degree. Related to the period immediately after anesthesia, women describe a worse state of health than men. Male and female patients do not differ in their satisfaction with anesthesiological care. Older patients describe greater satisfaction with perioperative care than younger ones. There are only a few significant correlations between the intensity of symptoms in the "recovery room" and data from anesthesiological documentation.

CONCLUSIONS

The new questionnaire is sensitive for the change of symptoms in the course of postoperative time. Considering the results, a modification of the questionnaire ist suggested. This instrument is to be used in a greater and representative sample of patients now.

[Management and methodological approaches for the assessment of emotional states in anesthesiology]

In anaesthesiology emotional states are of great importance. Reduction of anxiety and sedation in the preoperative preparation as well as stress reduction and the process of recovery are a challenge for anaesthetists as perioperative physicians. As emotions have different dimensions of manifestation like experience, expression, behaviour and somatic indicators, all these are needed to describe emotions sufficiently. In a multidimensional approach for the measure of emotional states, the different dimensions, their relationships and interactions are taken into account. The methodological approaches to registration of emotions in the anaesthesiological context are heterogeneous. In this summary the possibilities are differentiated by the source of information. Self-rating by the patient, rating by the observer, expression and behaviour and somatic indicators are taken into consideration. Analysis of the methods for the assessment of emotional states in anaesthesiological setting leads to the following recommendations: The most sensitive source of information is the patient. The rating scale used should be multidimensional and it should take specific as well as unspecific emotional aspects into account. As there are enough rating scales thoroughly developed and up to the demands of the classical test-theory, no ad hoc developed scales should be used. The rating of the emotional state should be supplemented by a rating of the physical state. The rating by the observer can be a valuable addition. The agreement between observers and the reliability of the method must be guaranteed. At presence there is no alternative in clinical practice to simple autonomic parameters such as blood pressure and heart rate as somatic indicators of emotion. Still it is important to consider the normal values for the individual patient. It is necessary to develop and to evaluate simple methods to register characteristics of expression in clinical context.

Effects of distance, age and sex upon attitudes toward nuclear power plants: an empirical study

Several aspects regarding nuclear power plants and works of the chemical industry were assessed by self-report inventories. The inventories included items related to attitudes and mood. Subjects (N = 228) were divided according to living distance to a nuclear power plant (up to 5 km, 5-10 km, 10-15 km), age (18-39 versus 40-59 years) and sex. Results demonstrate different risk perception referring to nuclear power plants and works of the chemical industry. Women and older persons reported more negative attitudes. In addition, the results confirm the assumption of an inverted U-shaped relationship between strength of negative attitudes toward nuclear power plants and distance of dwelling to the plant. The results are best explained by psychobiological models of stress.

[A comparison of the effect of propofol in 3 subhypnotic doses within the framework of tumor chemotherapy]

PURPOSE

In anaesthesia and critical care propofol is often used as a hypnotic or sedative. There are some reports showing propofol as a mood-altering drug. The use of propofol in subanaesthetic doses, for example in antineoplastic chemotherapy, led to similar results. In previous studies it was hypothesised that these mood effects could also reduce chemotherapy-induced nausea and vomiting. The present prospective randomised double-blind study evaluated mood effects of different subanaesthetic doses of propofol in oncology patients who received antineoplastic chemotherapy.

METHODS

Propofol was applied in a double-blind and randomised manner as follows (N = 8 per group): Initial bolus of 0.1 mg/kg followed by a continuous infusion of 1.0 mg/kgxh (group 1), 1.5 mg/kgxh (group 2) or 2.0 mg/kgxh (group 3). Dependent variables were as behavioural (i.e. nausea and vomiting) as aspects of mood as somatic aspects.

RESULTS

Subanaesthetic doses of propofol showed different effects. In respect of somatic variables some well-known results were replicated, showing highest reduction of blood pressure under highest dose of propofol. With regard to psychic variables no deterioration of mood or feeling tone was seen. Rather, a reduction of anxiety and especially under 2.0 mg/kgxh an induction of well-being occurred. However, even propofol was used as the only "anti-emetic" drug, patients reported no induction of nausea and vomiting during antineoplastic chemotherapy.

CONCLUSIONS

Further studies are needed to specify the "anti-emetic" effects of subhypnotic propofol in antineoplastic chemotherapy. Especially a comparison with a standard drug for the prevention of nausea and vomiting, such as ondansetron, will have to be conducted. The results of this study showed that a dose of propofol of 1.0 mg/kgxh after an initial bolus of 0.1 mg/kg is a useful reference dose.

Mood effects of zolpidem versus phenobarbital combined with promethazine in an anesthesiological setting

Zolpidem, a new imidazo-pyridine hypnotic, acts like a benzodiazepine. Because of its short half-life, zolpidem plays a special role in the group of drugs suitable for anesthesiological premedication because of its sedative and anxiolytic effects. The study compared preanesthesiological treatment by zolpidem and phenobarbital in combination with promethazine in a clinical setting. In a double-blind randomized design, 304 patients awaiting different kinds of surgery were studied. For the assessment of emotional states, a multidimensional rating scale was administered. The study showed differing effects of zolpidem and phenobarbital, which could be demonstrated in the scales 'irritation', 'vulnerability', and 'aggression' and could therefore represent in domain hostility. In most of the other scales there were similar effects of phenobarbital and zolpidem. Assuming that phenobarbital is a potent sedative, the reported results confirm the results found by other authors, that zolpidem also acts as a sedative. The reported results describe promethazine as selectively deactivating. These results are in agreement with the findings of an experimental study which tested the acute effects of stress under promethazine.

[Multidimensional psychometric assessment of preoperative mood. Effects of zolpidem compared to phenobarbital combined with promethazine as premedication]

The following double-blind, randomised study dealt with three questions: (1) Is a multidimensional psychometric rating scale suitable for the measurement of mood before anaesthesia? (2) What are the effects of the new benzodiazepine-like drug zolpidem on preoperative mood compared with phenobarbital? (3) Is the combination with Promethazine suggestive? METHODS. Three hundred and four patients were assigned to four groups (group 1: zolpidem 8.03 mg/promethazine 50 mg; group 2: zolpidem 8.03 mg/placebo; group 3: phenobarbital 100 mg/promethazine 50 mg; group 4: phenobarbital 100 mg/placebo). The drugs were given the evening before anaesthesia (09:30-10:00 p.m.). The sample was shifted by age and sex. Mood was measured by a multidimensional rating scale, which assessed aspects of elated mood, anxiety, hostility, deactivation, vigilance, and introversion. Statistics were performed using analysis of variance (ANOVA). RESULTS. Zolpidem led to significantly higher expressions of hostility (negative mood, irritability, aggressiveness) than phenobarbital. Compared with placebo, promethazine led to greater deactivation (more tiredness and numbness, lower level of wakefulness). Specific emotions and somatic aspects were not affected. Patients who had received promethazine received a lower dose of thiopentone for induction of anaesthesia than patients with placebo. CONCLUSIONS. Zolpidem and phenobarbital have many common effects on preoperative mood. Differences were found in the unspecific emotional aspects of agitation and hostility. These negative effects must be weighed against the pharmacokinetic and pharmacodynamic advantages of zolpidem when this drug is administered for premedication. The effects of zolpidem seem to be more sedative than anxiolytic. The study shows that a combination with promethazine is suggestive, because promethazine has a selective deactivating effect. The finding that promethazine lowers the dose of thiopentone required for induction of anaesthesia is an additional interesting point. The results of this study highlight the importance of using multidimensional rating scales for the measurement of mood before anaesthesia.

On the relation between ratings of the emotional state and expressive variables of gesture and verbal activities in old-aged people

Methods to assess emotional reactions in old-aged people are predominantly confined to physiological or biochemical variables. In an experiment the authors examined whether variables of gesture and verbal activity are indicators of emotional states. Ninety-six old-aged women took part in the experiment which had two experimental and two control conditions. Subjective variables, physiological variables, and variables of expression were assessed. The results show that emotional reactions are expressed in variables of verbal activity but not in variables of gesture.