Home Archive Vol.38, No.4, 2012 Original Papers The importance of analgosedation in postoperative periode

The importance of analgosedation in postoperative periode

 OANA-DIANA MARCOCI(1), MARIA VRABETE(2)

(1)Hospital of Tg-Jiu, (2)Department of Anesthesia and Intensive Care, Department of Normal and Pathological Physiology, University of Medicine and Pharmacy of Craiova

 

ABSTRACTWe observed and noted clinical  symptoms,.and  used screenig tests as tools for evaluating the values of pain and neuropsychiatric changes . We introduced as instrument of measurements: rating numerologic scale of pain, Ramsay Sedation Scale (RSS), criteria of  delirium diagnose , applied  in early period of arrousal (20 minutes- 4 hours) at the moment T1, at 4-7 hours : complete arrousal (T2) and at 72 hours (T3). Our pathophysiological, prospective randomised, clinical study, was approved by Ethic Commission of UMF and of Hospital nr.1 Craiova. We selected 100 patients from Plastic and Recontructive Surgery Department , with the aggrement of head of this section and having the patient accord. The most important conclusion of our study was that: appropriate information of patients about surgery and anesthesia, reduces preoperative anxiety, post-operative pain and hospital stay length.

KEYWORDS: pain, algosedation, neuropsychiatric changes screening tests.

 

Introduction

To the surgical  patients, in early postoperative period, it was  recorded: impaired memory and concentration, mild personality changes, cognitive changes,  and emotional instability.

Changes in mental function after anesthesia and surgery have been categorized into two distinct syndromes[3]:

-Postoperative delirium, a transient fluctuating disturbance of consciousness that occurs shortly after surgery

-POCD: change in cognitive performance, categorized according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as personality disorders, such as: schizoid, paranoid, histrionic, and depressive[1,2] . These personality disorders are the support for  psychiatric complications, which may install as disease in time, discovered  accidentally after a surgical intervention.

Materials and methods:

In our study  100 patients undergoing surgery at Plastic and Reconstructive Surgical operation room at Hospital nr.1 Craiova.. We have obtained the best predictor of postoperative psychological distress in preoperative psychological manifestations, using by us, as selection criteria of patients:

- age:15 ±35years old

-without comorbidity,(apparently healthy patients)

-acute trauma,reffered to posttraumatic woud of hand

-apparently. in a normal psychological and mintal status.

-smokers and alcohol drinkers do not excluded from study.

-existing the conditions to induce the anaesthesia and realise the perioperative preparing a management plan to minimise the impact of risks factors:  pain, thromboembolism and inadequate nutrition and hydration.

-having the possibility to  maintain functional reserve in each organ system for parallel patient's capability to maintain homeostasis in the face of surgical stress and the actions of anaesthetic drugs.

-excluding the patients to whom it was a preexisting therapy  with tricyclic antidepressants, because theese ones combined with halothan or sevoflurhane may increase catecholamine levels, and  sympathomimetic agents should be not use in such situations. Monoamine oxidase inhibitors interfere with the breakdown of central nervous system depressants. Potentially fatal adverse reactions are known to occur with meperidine, atropine, or other anticholinergic agents and with barbiturates. Because monoamine oxidase inhibitors increase the level of catecholamines in peripheral nerve endings and potentiate the effect of sympathomimetic agents, hypertensive crisis may result from the use of pressors and the diet must be low in tyramine (which is especially high in aged cheese). Hypertensive crisis may also occur when monoamine oxidase inhibitors are combined with other classes of antidepressants such as tricyclics, serotonin uptake inhibitors (e.g. fluoxetine), or bupropion.

 Criteria of patients exclusion from study group: existence of chronic pain, abuse of analgesic and sedatives drugs, recognition of psychiatric diseases, diagnosed in the past,  obesity (BMI > 30).

Methods

We applied the same kind of general anesthesia with oro-tracheal intubation. General anesthesia or programmed coma, could induce deep unconscious state, and  provides a “quiet” operating field by reducing organ activity and muscle movement. During the period of maintenance of anesthesia,  we combined sleep-inducing agents (hypnotics) with analgesics (relieve pain, but don’t block other sensations), muscle relaxants, and medication to relieve anxiety (commonly used drug is midazolam), which causes drowsiness, relieves anxiety, and acts on the brain to help block any memory of the procedure. Propofol (Diprivan) is given to induce unconsciousness. We used continous  infusion with poropol because its  activity is short installation of this one si rapid (usually within 40 seconds) and wears off quickly; thereafter during surgery.

 Analgesics blunt the body’s response to pain, helping steady the heart rate and blood pressure. While the patient is unconscious, the anesthesiologist monitors their vital functions and level of sedation and adjusts medications as needed. Following surgery, she may receive drugs to reverse the anesthesia or simply wake up as the medications wear off.

The anesthetic patrulater was obtained by means of association realised by anesthesiologist namely:  analgesia, hypnosis, antishock effect and relaxation. The adequacy of anestehsia could be observed  in: hemodynamic stability, good oxygenation, maintenance of hydro-ionic and oxidant/.antioxidant balances (redox). 

The Ramsay scale-6 levels:

Usually RSS has been used as a research tool for the comparison of sedative agents and  to express the variability of  responses of  different types of patients, submitted to anesthetic-surgical act.

Results

We identify six groups of  patients reactions:

-60% patients did not remember anything of the period between loss of consciousness (period of induction and maintenance of anesthesia ) and regaining it. For theese patients it was administered only local analgetics, no sedatives, or analgesics, in postoperative period.

-10% have had the memory of tracheal tube. This group, named the group with the experience of” recall / wakefulness, received peranethesic, ketamine or fentanyl, or a combination from both, (fentanyl was antagonised with: naloxon).  To this group it was given: meperidine, in T1 and T2, depending of their needs.

-15% cases: have had dreams and nigtmares. They need local analgesic therapy in T1, (for those with dreams) and sedatives and analgesics for those with nightmares.

-3% cases hallucinations and suicidal tentatives, had needs of psychiatric consultations, psychiatric therapy and they were transferred to the psychiatric hospital They was considered to manifest a crisis of delirium

-10%Anxious patients  evidentiated their misconceptions about surgery, reflected in their  reactions to trauma. We have prescribed benzodiazepines, for preoperative anxiety, but the best effect obtained, in reducing preoperative anxiety and have additional post-operative benefits, was the dialog between psychologist, surgeon, anesthesiologist and patients.

Phobias:appear in five men as: needle phobias.

We appreciated that an efficient treatment of their anxiety has could be the  contact with others who have successfully completed a similar operative procedure.

-2%For patients who have had chronic anxiety disorders we adminstered anxiolytic agents, and obtained a favourable effect.

 

Fig.1. Postoperative patients reactions

Cognitive impairments have metabolic origin, especially in alcoholism , and we observed to be associated with the risk of postoperative delirium (7% cases). and suicidal tentative (2% cases).

Surgical recommandation to treat local wound using: non-steroidal anti-inflammatory drugs and local anaesthetics was associated with opioids such : meperidine, in fractioned doses (25 mg/ 4 hours), from early arrousal until 24 hours postoperative (20% cases).

In the postoperative period, a confluence of factors , such as  drug effects, poor pain control, unfamiliar environment and sensory deprivation, increased  the prevalence of delirium to 17% of patients. In this situations, we observed that majority of patients shows the benefits of multi component therapy aimed at each ones, of the known risk factors, that include:

-immobility

-dehydration

-cognitive impairment

-sleep deprivation.

For chronic patients with anxiety, sudden cessation following administration of anxiolytics was associated with rebound anxiety as well as by withdrawal symptoms (4% cases).  Administration of benzodiazepines provided sedation. Intravenous lorazepam are equipotential for the treatment of generalized anxiety.The number of patients diagnosed as having delirium, in relation to the total score of checklist was of two cases (2%).

We analysed the perioperative and postoperative values of the parameters,such as:

-pain appearence (Fig.2)

- incidence of recall, in early postoperative period and therapy applied

Fig.2.Pain appearance

Table 1.Incidence of recall,  in early postoperative period and therapy applied.

Event

T1

T2

T3

Recall

43(dyn)

-

-

No recall

20(mep)

5(mep)

2(mep)

Dreams

10(Dyn)

 

 

Nightmares

5(S A)

2(S)

 

Hallucinations

2(prop)

2(psy)

2(psy)

Legend: Dyn: dynastat (80 mg), MEP: meperidine(100 mg), S: sedatives (diazepam), A: Analgesics Prop: propofol: 100 mg..Psy: Psychiatric consultation.

 

Fig.3. Types of algosedation used

No sedation 70 cases.

Patients who experienced wakefulness were youger.

Patients who remembered dreams needed longer sedation

-biological parameters: The values of ROS increase progressively from  T1 to T3, inducing the excessive  consum of endogenous  antioxidants. NO production decrease, so vasoconstriction, hypoperfusion and hypercoagulability of plasma can appear. Amplification of these events influence in a nefavourable manner the evolution of wound healing.

Table 2.  Value of ROS, NO

GR.

T1- ROS

T1-NO

T2-ROS

A

0,2 ± 0,011

0,75 ± 4,76

 

B

0,24 ± 0,096

0,22 ± 4,41

0,75 ± 0,157

C

0,43 ± 0,235

0,10 ± 3,14

0,60 ± 0,298

GR.

T2-NO

T3-ROS

T3-NO

A

-

-

-

B

0,13 ± 0,22

0,23 ± 0,541

68 ± 0,237

C

0,06 ± 0,52

1,04 ± 0,45

0,321 ± 0,345

Discussions

Pain, as a dual manifestation: periferic and central. is presented in postoperative period, usually associated with sympathetic hyperactivity reflected in increasing of heart rate, arterial pressure, myocardial oxygen consumption, all of these ones, leading to myocardial ischaemia. The reducing of the movements of the chest wall and diaphragma causes the postoperative atelectasis, which could be installed, frequently.Because of these manifestations, analgesia is necessary not only to ameliorate the amplitute of respiration. but also, for extubation, when patient is weanned from mechanical ventilation to spontaneous respiration and endotracheal tube is removed. Continuing the sedation can attenuate the cardiovascular stress response, over extubation. The benefits of algosedation are reffered to the favourable effects upon.the neuroendocrine stress response , including: release of adrenocorticotropic hormone (ACTH), prolactin, growth hormone,vasopressin (from the pituitary gland), cortisol , aldosterone and cathecolamines, from adrenals associated with glucagon secretion and insulin suppression[4,5]. This endocrine axis increase the inflammatory response, that means cytokines, prostaglandines, and P substance eliberation, creating a vicious circle, amplifying pain and conditions for infectiouse complications apperance.. The degree of traumatic or postoperative injuries is obtained evaluating the periferic pain, (clinical local aspect, morpho-pathologic, biochemical parameters) s senzitivity to pain is very complex from each to other, and because of this characteristic analgetic¢and the psycho-affective colour of this one, as central pain. The patient strategies have to be individualised. Ussually it is recommanded to asociate: opioids, with non steroidal anti inflammatory drugs and may be with local anesthetics.

Pain is associated with sympathetic hyperactivity , and for that, deacreasing sympathetic tone and oxygen consumption, could stabilise the haemmodynamics and treat agitation and motor activity. Sedation and analgesia correctly administered in postoperative period, protect patient against stressfull stimuli and provide anxiolysis, nocturnal sleep and amnesia. Propofol approaches the ideal sedative drug, having favourable effects on intracranial haemmodynamics, but hypotension, primarily appeared because of systemic vascular resistance reduction, may compromise cerebral perfusion pressure and negate its benefits.

Benzodiazepines, used for anxiolysis and sedation, bind to receptors on macrophages and inhibit their ability to produce IL1, IL6 and TNF-alpha6,7]. Supplementally thses kind of substances, the same, like propofol, have an important antioxidant effect[8]

 Conclussions

1.The disproportion between the intensity of pain and local morphopathological changes of surgical wound is due to the differatiation between the periferic segment , which need an antinflammatory medication and central segment, emotional one, which need sedation.

2. Sedation and analgesia protect patients from the noxius stimuli, provide anxiolysis, nocturnal sleep and amnesia and also, decrease the sympathetic tone , oxygen consumption, maintain heamodynamic stability and elininate motor agitation.

3.Alimentation reflects social conditions, education, behaviour and could influenc the wound healing, especially for those who include antioxidants elements, in their diet, represented by vegetables. and fruits.

4.Preoperative participation of a psychiatrist may be especially helpful in high risk procedures and when there is a critical demand for patient monitoring; whenever the surgeon suspects significant psychopathology, or when there is a prior history of postoperative psychiatric difficulty (such as amputation of one segment finger,or of hand).

5.To select an effective medical agent, means that this one to have the ability to reduce an make reversible the consciousse level.

6. It is necessary to select a safe drug : to have no effect on the cardio-vascular, respiratory systems and metabolism,to do not exacerbate neuro-vegetative effects hypersensitivity reactions, histamine release and pain on injection at the site of venous punction.

References:

1.   Ahlgren E, Lundqvist A, Nordlund A, Aren C, Rutberg H. Neurocognitive impairment and driving performance after coronary artery bypass surgery. European Journal of Cardio-Thoracic Surgery 2003; 23: 334–40.

2.   Fodale V, Schifilliti D, Praticò C, Santamaria LB. Remifentanil and the brain. Acta Anaesthesiologica Scandinavica 2008;52:319-26.

3.   Fodale V,Quattrone D,Trecroci C,Caminiti V,Santamaria LB. Alzheimer's disease and anaesthesia: implications for the central cholinergic system.British  Journal 0f Anaesthesia. 2006 Oct;97(4):445-52.

4.   Jacobi J, Fraser GL, Coursin DB, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002; 30: 119-141.

5.   Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical careSemin Respir Crit Care Med 2001; 22: 211-225

6.   Cibelli M, et al. Microglia and astrocyte activation in the hippocampus in a model of orthopedic surgery in adult miceAnesthesiology 2007; 107:A1557.

7.   Wan Y, et al. Postoperative impairment of cognitive function in rats. A possible role for cytokine-mediated inflammation in the hippocampus. Anesthesiology 2007; 106:436–43.

8.   Zeiler SR , Kaplan PW. Propofol withdrawal seizures (or not). Seizure 2008;17:665–7.

 


Correspondence address: Diana Marcoci, Str. Dambovita, 48/3, Craiova. E-mail: dianaomd@yahoo.com

 


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