Allodynia is a common and disabling symptom in many patients with neuropathic pain. Whereas quantification of pain mostly depends on subjective pain reports, allodynia can also be measured objectively with quantitative sensory testing. In this pilot study, we investigated the clinical relevance of quantitative sensory testing with Von Frey monofilaments in patients with allodynia as a consequence of a neuropathic pain syndrome, by means of correlating subjective pain scores with pain thresholds obtained with quantitative sensory testing.

During a 4-week trial, we administered a cannabis extract to 17 patients with allodynia. We quantified the severity of the allodynia with Von Frey monofilaments before, during and after the patients finished the trial. We also asked the patients to rate their pain on a numeric rating scale at these three moments.

We found that most of the effect of the cannabis occurred in the last 2 weeks of the trial. In this phase, we observed that the pain thresholds, as measured with Von Frey monofilaments, were inversely correlated with a decrease of the perceived pain intensity.

These preliminary findings indicate clinical relevance of quantitative sensory testing with Von Frey monofilaments in the quantification of allodynia in patients with neuropathic pain, although confirmation of our data is still required in further studies to position this method of quantitative sensory testing as a valuable tool, for example, in the evaluation of therapeutic interventions for neuropathic pain.

To study the effect of 0.2 mg mL−1 of ondansetron added to morphine patient-controlled analgesia solution after a 4 mg loading dose on the incidence and severity of postoperative nausea and vomiting.

One hundred and sixty patients scheduled for elective surgery, between 18 and 65 yr old, were studied. Patients who smoked, received antiemetics and hormonal therapy, had a history of motion sickness or gastrointestinal disease, a body mass index >35 or menstruation at the time of the study were excluded. Patients were assigned to the ondansetron and control groups by block randomization. At the end of anaesthesia, all patients received 4 mg of ondansetron intravenously and the same patient-controlled analgesia regimen of morphine. The ondansetron group (n = 80) received 0.2 mg of ondansetron per 1 mg of morphine. The nausea score, vomiting score and the requested ondansetron dose were evaluated at 1, 2, 6, 12 and 24 h. Patient-satisfaction for nausea/vomiting was recorded at the end of the study.

Patient characteristics and cumulative morphine consumption were similar but ondansetron group had higher pain scores (P = 0.006). The ondansetron group had a lower nausea and vomiting scores, and more patients were free from nausea and vomiting than the control group (41 vs. 26, respectively, P = 0.025). The ondansetron group had fewer cumulative ondansetron doses than the control group and better patient satisfaction than the control group (P < 0.05).

Ondansetron 4 mg plus 0.2 mg mL−1 given with PCA morphine can reduce nausea and vomiting thus improving patient satisfaction.

Inadvertent perioperative hypothermia causes serious morbidity in surgical patients. However, recent reports suggest that patients might still be hypothermic after elective surgery. We thus surveyed intraoperative temperature monitoring and management practices in Europe.

Postal survey of 801 representative hospitals from 17 European countries on the same day. The questions addressed the number of surgical procedures and type of anaesthesia performed, mode and site of temperature monitoring and method of patient warming. Mean and standard error of the mean or count and percentage were calculated. The t-test or contingency table analysis with the Fisher’s exact test were used.

Eight thousand and eighty-three surgical procedures were assessed from 316 responding hospitals (39.4%). Overall, patient temperature monitored in 19.4% and 38.5% of the patients were actively warmed. Under general anaesthesia, body temperature was monitored in 25% and during regional anaesthesia in 6%, P = 0.0005. Nasopharyngeal temperature was most often taken under general anaesthesia, while tympanic temperature was preferred during regional anaesthesia. Under general anaesthesia, 43% of patients were actively warmed as compared to 28% with regional anaesthesia, P = 0.0005. Forced-air warming was the method of choice for both general and regional anaesthesia.

Intraoperative temperature monitoring is still uncommon and hence active patient warming is not a standard of care in Europe. Awareness of perioperative hypothermia is critical to its prevention, and thus temperature monitoring is a pre-requisite. The objective is to maintain normothermia in patients throughout surgery. A European practice guideline for perioperative patient temperature management is warranted.

Mortality prediction systems have been calculated and validated from large mixed ICU populations. However, in daily practice it is often more important to know how a model performs in a patient subgroup at a specific ICU. Thus, we assessed the performance of three mortality prediction models in four well-defined patient groups in one centre.

A total of 960 consecutive adult patients with either severe head injury (n = 299), multiple injuries (n = 208), abdominal aortic aneurysm (n = 267) or spontaneous subarachnoid haemorrhage (n = 186) were included. Calibration, discrimination and standardized mortality ratios were determined for Simplified Acute Physiology Score II, Mortality Probability Model II (at 0 and 24 h) and Injury Severity Score. Effective mortality was assessed at hospital discharge and after 1 yr.

Eight hundred and fifty-five (89%) patients survived until hospital discharge. Over all four patient groups, Mortality Probability Model II (24 h) had the best predictive accuracy (standardized mortality ratio 0.62) and discrimination (area under the receiver operating characteristic curve 0.9), but Simplified Acute Physiology Score II performed well for patients with subarachnoid haemorrhage. Overall calibration was poor for all models (Hosmer–Lemeshow Type C-values between 20 and 26). Injury Severity Score had the worst discrimination in trauma patients. All models over-estimated hospital mortality in all four patient groups, and these estimates were more like the mortality after 1 yr.

In our surgical ICU, Mortality Probability Model II (24 h) performed slightly better than Simplified Acute Physiology Score II in terms of overall mortality prediction and discrimination; Injury Severity Score was the worst model for mortality prediction in trauma patients.

Electroencephalographic entropy is used to measure the degree of brain hypnosis and anaesthesia depth. Two parameters are displayed in the monitor, state entropy (SE) and response entropy (RE). Ageing leads to reduction in liver mass as well as hepatic blood flow, which decreases clearance of propofol and increases the risk of cardiovascular adverse effects. The aim of this study is to demonstrate the effect of electroencephalographic entropy on propofol requirement and haemodynamic parameters during induction of anaesthesia in elderly patients.

We studied 72 elderly patients. Standard monitoring was performed for all patients together with entropy monitor. Patients were allocated randomly either to the control group, which were given the recommended induction dose of propofol, or to the entropy group which was induced with propofol based on entropy reading where the end-point was SE 50 and SE-RE difference less than 10. Propofol induction doses and haemodynamic changes were recorded. Anaesthesia was maintained using sevoflurane and O2 air mixture.

After induction of anaesthesia, the systolic, diastolic, mean arterial pressure, RE and SE were significantly lower in the control group (P value < 0.05). Total dose of propofol and the dose kg−1 were significantly reduced by 37.1% and 31.8%, respectively, in the entropy group (P value < 0.01).

The use of electroencephalographic entropy during induction of anaesthesia in elderly patients reduces propofol requirements and maintains cardiovascular stability.

During high epidural anaesthesia, endothelin only contributes minimally to blood pressure stabilization. This phenomenon could result from the inhibitory action of nitric oxide on the endothelin system. To clarify this, we studied the interaction between nitric oxide and endothelin during high epidural anaesthesia in conscious dogs, in comparison to the interaction of nitric oxide and vasopressin.

Six animals were used in 45 individual experiments randomly arranged as follows: N-ω-nitro-arginine-methylester 0.3–10 mg kg−1 under physiological conditions or during high epidural anaesthesia (lidocaine 1%) and N-ω-nitro-arginine-methylester (l-NAME) 0.3–10 mg kg−1 after preceding endothelin (Tezosentan®) or vasopressin (β-mercapto-β,β-cyclo-penta-methylene-propionyl-O-Me-Tyr-Arg-vasopressin) receptor blockade under physiological conditions or during high epidural anaesthesia. During control experiments normal saline was injected either intravenously (n = 5) or into the epidural space (n = 4).

N-ω-nitro-arginine-methylester increased mean arterial pressure dose-dependently in all groups. However, this effect was substantially reduced in the presence of the endothelin receptor antagonist compared to N-ω-nitro-arginine-methylester alone, both under control conditions (7 ± 3 vs. 21 ± 3 mmHg; P < 0.05) and during high epidural anaesthesia (17 ± 3 vs. 30 ± 1 mmHg; P < 0.05). Blockade of vasopressin showed no similar relationship with N-ω-nitro-arginine-methylester.

The diminished increase in mean arterial pressure after injection of N-ω-nitro-arginine-methylester only during endothelin receptor blockade indicates that endogenous nitric oxide inhibits the action of endothelin during high epidural anaesthesia and might thus explain the reduced efficacy of endothelin in maintaining blood pressure during high epidural anaesthesia.

Postoperative nausea and vomiting is a common complication following strabismus surgery. This randomized and double-blind study was designed to evaluate the efficacy of midazolam alone or in combination with dexamethasone in reducing the incidence of postoperative nausea and vomiting in children undergoing strabismus repair.

One hundred ASA I children, aged 4–12 yr, scheduled to undergo elective strabismus surgery, were enrolled. No premedication was given. Anaesthesia was induced with sevoflurane, nitrous oxide and oxygen. After induction, fentanyl 2 μg kg−1 and cisatracurium 0.1 mg kg−1 were administered and an endotracheal tube was inserted. After induction of anaesthesia and before start of surgery, patients were randomly allocated into one of four groups of 25 children each to receive placebo, midazolam 50 μg kg−1, dexamethasone 0.5 mg kg−1 or a combination of midazolam 50 μg kg−1 and dexamethasone 0.5 mg kg−1. Episodes of nausea, and retching and vomiting were recorded during the first 24 h after surgery.

The incidence of postoperative nausea was 48%, 32%, 12% and 0% with placebo, dexamethasone, midazolam and the midazolam–dexamethasone combination, respectively. The incidence of vomiting was 52% and 32% with placebo and dexamethasone, respectively; no child vomited with midazolam alone, or with the midazolam–dexamethasone combination.

Prophylactic midazolam with or without dexamethasone reduces the incidence of PONV in children undergoing strabismus repair.

Tricyclic antidepressants are commonly employed orally to treat major depressive disorders and have been shown to be of substantial benefit in various chronic pain conditions. Among other properties they are potent Na+ channel blockers in vitro and show local anaesthetic properties in vivo. The present study aimed to determine their differential neurotoxicity, and that of novel derivatives as prerequisite for their potential use in regional anaesthesia.

To directly test neurotoxicity in adult peripheral neurons, the culture model of dissociated adult rat primary sensory neurons was employed. Neurons were incubated for 24 h with amitriptyline, N-methyl-amitriptyline, doxepin, N-methyl-doxepin, N-propyl-doxepin, desipramine, imipramine and trimipramine at 100 μmol, and at concentrations correlating to their respective potency in blocking sodium channels.

All investigated substances showed considerable neurotoxic potency as represented in significantly decreased neuron numbers in cultures as compared to controls. Specifically, doxepin was more neurotoxic than amitriptyline, and both imipramine and trimipramine were more toxic than desipramine or amitriptyline. Novel derivatives of tricyclic antidepressants were, in general, more toxic than the parent compound.

Tricyclic antidepressants and novel derivatives thereof show differential neurotoxic potential in vitro. The rank order of toxicity relative to sodium channel blocking potency was desipramine < amitriptyline < N-methyl amitriptyline < doxepin < trimipramine < imipramine < N-methyl doxepin < N-propyl doxepin.

The French legislature passed a law in 2005 that assigns a new role to the physician and redefines his liability in end-of-life decisions.

This law is presented and discussed in context with current French legal practice.

This law emphasizes patient autonomy, advocating that the patient be fully informed before treatment, and creates specific procedures to be followed according to whether the patient is conscious or unconscious. In the latter situation, the law reinforces the role of both the patient’s surrogate and the patient’s advance directives in establishing consent. In these extreme situations, doctors have the option to request a second medical opinion. This joint decision-making procedure is laid down by law and becomes obligatory in the interests of transparency.

Respect for patients’ consent implies the possibility that they may refuse medical care, creating an ethical and legal dilemma of providing medical care or respecting the patients’ wishes. The key issue concerning end-of-life patients rests in the decisions taken concerning the continuation or withdrawal of life support and the administration of palliative care.

The efficacy, tolerability and the morphine-sparing effects of lornoxicam were compared with those of tenoxicam when used preoperatively in patients undergoing laparoscopic cholecystectomy.

In this prospective, double-blind study, 60 ASA I–II patients undergoing laparoscopic cholecystectomy were randomized equally to receive intravenous tenoxicam 40 mg (Group T) or lornoxicam 16 mg (Group L), preemptively. Three patients withdrew from the study, so 57 patients were included in the analysis. In the postoperative period, the first morphine demand times, pain scores, side-effects and cumulative morphine consumptions were evaluated during the first 24 h.

The patient characteristics data and the duration of surgery were similar between two groups, except for body weights (P = 0.002). The first morphine demand time was significantly longer in Group L (P = 0.037), but the pain levels did not differ. The mean pain scores were higher in Group T in the 15 min (P = 0.036), 1 h (P = 0.020), 2 h (P = 0.001) and 4 h (P = 0.0042) after extubation. A statistically significant difference between two groups was found in calculated cumulative morphine consumptions per kilogram in the 15 min (P = 0.037), 30 min (P = 0.016), and 1 h (P = 0.004) and 2 h (P = 0.013) between two groups. There was no difference in the severity of nausea but 13 patients in Group T and five patients in Group L had vomiting (P = 0.018). Patient satisfaction was similar in the two groups.

Preoperatively administered lornoxicam 16 mg significantly prolonged the first morphine demand time, reduced postoperative morphine consumption during the first 4 h and caused significantly fewer adverse effects when compared with tenoxicam after laparoscopic cholecystectomy.