sgpgi.ac.in

OBJECTIVE: Laparoscopic donor nephrectomy (LD) is rapidly gaining popularity, however, this may not be affordable by donors in many developing countries because of its high cost. We describe our mini flank incision (MD) donor nephrectomy technique and its outcome. METHODS: A 7-10-cm subcostal rib sparing transverse incision was given 2 cm lateral to the tip of the 12th rib, towards the lateral border of rectus muscle. All dissections were performed with help of long retractors and instruments, vessels were transfixed and cut. In last 45 cases, vessels were clipped with Liga or Weck clips. Donors and recipients outcome was analysed. RESULT: From January 2000 to December 2002 a total of 148 patients underwent donor nephrectomy by mini incision technique. Mean patient age was 44.8 +/- 7.3 yr (range 20-70 yr). Nephrectomies were performed in 115 patients on the left side and in 33 cases on the right side. The mean incision length was 9.1 +/- 1.8 cm (range 7-10 cm). Mean operative time was 105 +/- 10.5 min (70-130 min). Mean analgesic (Tramadol) requirement was 205 +/- 52 mg; postoperative hospital stay was 2.2 +/- 0.5 d. Twelve per cent patients developed fever and 4% had superficial wound infection in postoperative period. Three patients required blood transfusion. Mean convalescence period was 22 +/- 2.8 d. CONCLUSION: Extrapleural, extraperitoneal, subcostal mini incisions live donor nephrectomy is a relatively safe procedure with low morbidity. This technique has a shorter hospital stay, early convalescence and better cosmesis. It is cost-effective and is an ideal substitute for the developing country.

Tramadol reference source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14756264&dopt=Abstract tramadol Ultram [PubMed - in process]




J Clin Psychiatry. 2004 Feb;65(Supplement 2):5-19.
Introduction: Methods, Commentary, and Summary.

Alexopoulos GS, Streim J, Carpenter D, Docherty JP.

OBJECTIVES. Antipsychotics are widely used in geriatric psychiatric disorders. A growing number of atypical antipsychotics are available, expanding clinical options but complicating decision-making. Many questions about use of antipsychotics in older patients remain unanswered by available clinical literature. We therefore surveyed expert opinion on antipsychotic use in older patients (65 years of age or older) for recommendations concerning indications for antipsychotics, choice of antipsychotics for different conditions (e.g., delirium, dementia, schizophrenia, delusional disorder, psychotic mood disorders) and for patients with comorbid conditions or history of side effects, dosing strategies, duration of treatment, and medication combinations. METHOD. Based on a literature review, a 47-question survey with 1,411 options was developed. Approximately three quarters of the options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For other options, experts were asked to write in answers. The survey was sent to 52 American experts on treatment of older adults (38 geriatric psychiatrists, 14 geriatric internists/family physicians), 48 (92%) of whom completed it. In analyzing responses to items rated on the 9-point scale, consensus was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred, second line/alternate, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean. Guidelines indicating preferred treatment strategies were then developed for key clinical situations. RESULTS. The expert panel reached consensus on 78% of options rated on the 9-point scale. The experts did not recommend using antipsychotics in panic disorder, generalized anxiety disorder, nonpsychotic major depression, hypochondriasis, neuropathic pain, severe nausea, motion sickness, or irritability, hostility, and sleep disturbance in the absence of a major psychiatric syndrome. However, antipsychotics were favored in several other disorders. For agitated dementia with delusions, the experts' first-line recommendation is an antipsychotic drug alone; they would also consider adding a mood stabilizer. Risperidone (0.5-2.0 mg/day) was first line followed by quetiapine (50-150 mg/day) and olanzapine (5.0-7.5 mg/day) as high second-line options. There was no first-line recommendation for agitated dementia without delusions; an antipsychotic alone was high second line (rated first line by 60% of the experts). The experts'first-line recommendation for late-life schizophrenia was risperidone (1.25-3.5 mg/day). Quetiapine (100-300 mg/day), olanzapine (7.5-15 mg/day), and aripiprazole (15-30 mg/day) were high second line. For older patients with delusional disorder, an antipsychotic was the only treatment recommended. For agitated nonpsychotic major depression in an older patient, the experts' first-line recommendation was an antidepressant alone (77% first line); second-line options were an antidepressant plus an antipsychotic, electroconvulsive therapy (ECT), an antidepressant plus a benzodiazepine, and an antidepressant plus a mood stabilizer. For nonpsychotic major depression with severe anxiety, the experts recommended an antidepressant alone (79% first line) and would also consider adding a benzodiazepine or mood stabilizer to the antidepressant. If an older patient with adequate dosages for adequate duration, there was limited support for adding an atypical antipsychotic to the antidepressant (36% first line after two failed antidepressant trials). Treatment of choice for geriatric psychotic major depression was an antipsychotic plus an antidepressant (98% first line), with ECT another first-line option (71% first line). For mild geriatric nonpsychotic mania, the first-line recommendation is a mood stabilizer alone; the experts would also consider discontinuing an antidepressant if the patient is receiving one. For severe nonpsychotic mania, the experts recommend a moodd stabilizer alone; the experts would also consider discontinuing an antidepressant if the patient is receiving one. For severe nonpsychotic mania, the experts recommend a mood stabilizer plus an antipsychotic (57% first line) or a mood stabilizer alone (48% first line) and would discontinue any antidepressant the patient is receiving. For psychotic mania, treatment of choice is a mood stabilizer plus an antipsychotic (98% first line). Risperidone (1.25–3.0 mg/day) and olanzapine (5–15 mg/day) were first-line options in combination with a mood stabilizer for mania with psychosis, with quetiapine (50–250 mg/day) high second line. If a patient has responded well, the experts recommended the following duration of treatment before attempting to taper and discontinue the antipsychotic: delirium, 1 week; agitated dementia, taper within 3–6 months to determine the lowest effective maintenance dose; schizophrenia, indefinite treatment at the lowest effective dose; delusional disorder, 6 months–indefinitely at the lowest effective dose; psychotic major depression, 6 months; and mania with psychosis, 3 months. For patients with diabetes, dyslipidemia, or obesity, the experts would avoid clozapine, olanzapine, and conventional antipsychotics (especially low- and mid-potency). Quetiapine is first line for a patient with Parkinson's disease. Clozapine, ziprasidone, and conventional antipsychotics (especially low- and mid-potency) should be avoided in patients with QTc prolongation or congestive heart failure. For patients with cognitive impairment, constipation, diabetes, diabetic neuropathy, dyslipidemia, xerophthalmia, and xerostomia, the experts prefer risperidone, with quetiapine high second line. More than a quarter of the experts considered these combinations contraindicated: clozapine + carbamazepine, ziprasidone + tricyclic antidepressant (TCA), and a low-potency conventional antipsychotic + fluoxetine. In combining antidepressants and antipsychotics, the experts would be much more cautious with selective serotonin reuptake inhibitors that are more potent inhibitors of the CYP 450 enzymes (i.e., fluoxetine, fluvoxamine, paroxetine) and with nefazodone, TCAs, and monoamine oxidase inhibitors. The experts recommended extra monitoring when combining any antipsychotic with lithium, carbamazepine, lamotrigine, or valproate (except aripiprazole, risperidone, or a high-potency conventional plus valproate) or with codeine, phenytoin, or tramadol. CONCLUSIONS. The experts reached a high level of consensus on many of the key treatment questions. Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide direction for common clinical dilemmas in the use of antipsychotics in elderly patients. Clinicians should keep in mind that no guidelines can address the complexities of an individual patient and that sound clinical judgment based on clinical experience should be used in applying these recommendations.

Tramadol reference source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14761211&dopt=Abstract tramadol Ultram [PubMed - as supplied by publisher]




Minerva Anestesiol. 2004 Jan-Feb;70(1-2):45-52.
Analgesic transition after remifentanil-based anesthesia in neurosurgery. A comparison of sufentanil and tramadol.

Cafiero T, Burrelli R, Latina P, Mastronardi P.

Department of General and Specialistic, Surgical Sciences, A. Cardarelli Hospital, Naples, Italy.

AIM: Transition from the end of remifentanil infusion and postoperative analgesia must be planned carefully owing to remifentanil's (R) rapid offset. Intraoperative morphine has been used for the transition to postoperative analgesia following remifentanil-based anesthesia. Sufentanil (S) is a very potent opioid with high micro-receptor affinity, a much wider therapeutic index and a lower fractional receptor occupancy. These pharmacological and dynamics features make sufentanil an interesting alternative to morphine for immediate postoperative analgesia. METHODS: Experimental design: perspective, randomized, single blinded and comparative study. Institution: neurosurgical operating theatre at University. Patients: 96 patients, aging from 25 to 67 years, ASA class I-III, undergoing neurosurgical operations, were studied. Interventions and Measurements: the anesthetic management was: premedication: atropine 0.01 microg kg(-1) + remifentanil 0.20 microg kg(-1) min(-1); induction: propofol 2.0 microg kg(-1) + cisatracurium 0.15 microg kg(-1); maintenance: sevoflurane 0.8% + remifentanil (titrated infusion) cisatracurium. All patients received ketorolac 30 mg i.v. 1 hour before the end of surgery and ketorolac (60-90 mg) + tramadol (200-300 mg) by elastomeric pump; patients were divided into 2 groups: group T receiving tramadol 100 mg and group S receiving a bolus dose of sufentanil 0.10 microg kg(-1), 30 and 15 minutes before the end of surgery respectively. Recovery time, postoperative analgesia evaluated by VAS, cardiocirculatory parameters and side effects like nausea, vomiting, shivering, muscle rigidity, sedation and respiratory depression were recorded. RESULTS: VAS was significantly lower in Group S. Recovery time was shorter in Group T than in Group S (8.8+/-3.6 vs 11.6+/-4.6 min), no statistically significant differences between groups as regards nausea, vomiting and shivering. Short-lasting respiratory depression was detected in 3 cases in Group S. CONCLUSION: At the emergence much better control of the transition phase in patients treated with sufentanil: smooth recovery with better tolerability of the endotracheal tube; efficacious analgesia along with cardiocirculatory stability.

Tramadol reference source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14765044&dopt=Abstract tramadol Ultram [PubMed - in process]




S Afr J Surg. 2003 Nov;41(4):86-8.
Tramadol--a multimodal, multipurpose analgesic for the surgeon.

Shipton EA.

Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.

Tramadol is a multimodal analgesic with proven dose-related efficacy over a variety of perioperative surgical fields and is efficacious in treating both neuropathic and cancer pain. It is of particular use in patients with impaired cardiorespiratory, hepatic or renal function, and is an important addition to the armamentarium of the surgeon.

Tramadol reference source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14768142&dopt=Abstract tramadol Ultram [PubMed - in process]




Zentralbl Gynakol. 1992;114(11):551-4.
[Use of tramadol versus pethidine versus denaverine suppositories in labor--a contribution to noninvasive therapy of labor pain]

[Article in German]

Bredow V.

Klinik und Poliklinik fur Frauenheilkunde und Geburtshilfe, Medizinischen Fakultat, Ernst-Moritz-Arndt-Universitat Greifswald.

Because tramadol does not exhibit an depressive effect on ventilatory activity it is often be used in the obstetrical analgesia, at most in form of an intramuscularly injection. In a prospective study on at all 49 women under labour the clinical effect of the noninvasive rectal application of Tramadol, Pethidin, and Denaverin has been compared. The first dosage was 100 mg of all substances. Around the half of the women said that analgetic effect was good or very good. On only every fifth it was sufficient or not enough. The effect was at near the same in all treatment groups. Because of a low incidence of maternal side effects, the absence of side effects on the newborn, and near the same results on the analgetic effect of parenteral application in other studies, tramadol suppositories can be recommended for obstetrical analgesia.

Tramadol reference source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1481587&dopt=Abstract tramadol Ultram