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Papers by Jorge Jiménez Cruz
Journal of Clinical Medicine
Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This st... more Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This study investigated postoperative pain after CS using patient-related outcomes (PROs) to identify risk factors for severe pain. The secondary outcome was to evaluate the influence of surgery indication (primary CS (PCS) vs. urgent CS (UCS)). This multi-center, prospective cohort study included data submitted to the pain registry “quality improvement in postoperative pain treatment” (QUIPS) between 2010 and 2020. In total, 11,932 patients were evaluated. Median of maximal pain was 7.0 (numeric rating scale (NRS) 0 to 10); 53.9% suffered from severe pain (NRS ≥ 7), this being related to impairment of mood, ambulation, deep breathing and sleep, as well as more vertigo, nausea and tiredness (p < 0.001). Distraction, relaxation, mobilization, having conversations, patient-controlled analgesia (PCA) and pain monitoring were shown to be protective for severe pain (p < 0.001). Maximal pain in...
Journal of Orthopaedic Surgery and Research
Background Insufficient pain control after lower limb arthroplasty results in delayed recovery an... more Background Insufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA). Methods All patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir. Results The analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], ...
Poorly managed postoperative pain may prolong length of stay, cause postoperative complications, ... more Poorly managed postoperative pain may prolong length of stay, cause postoperative complications, diminishes quality of life, and causes needless suffering. Severe post-operative pain is a risk factor for developing chronic pain which may increase economic costs and has a negative impact on patient and family quality of life (1). Thus, optimizing management of pain is both humane and cost effective. Nevertheless, management of post-operative pain remains unsatisfactory worldwide. Despite the availability of high-quality guidelines and advanced pain management techniques acute post-operative pain management is still not satisfactory (2). In gynaecology and obstetrics, hysterectomies and caesarean sections belong to the most frequent and rather painful surgeries (3, 4). One reason for the described deficits is the fact that most clinicians lack of valid information on the quality of their pain management because data on processes and outcomesif it all-are not collected in a standardized way. Moreover, even if quality deficits are identified, there is often considerable resistance towards change of daily practices. The PAIN OUT (Improvement in Postoperative Pain Outcome) is a multinational quality improvement and research project that provides a unique and user-friendly web-based information system. It aims to improve treatment of patients with post-operative pain by means of standardised data acquisition, analysis of quality and process indicators, and feed back and benchmarking. The project focusses on patient-reported outcomes, using the short International Pain Outcome questionnaire which is validated in more than 10 languages. From 2009-2012, it was funded by European Commission's 7th Framework Programme. Since 2013, PAIN OUT is being continued in cooperation with professional societies, e.g. the International Association for the Study of Pain (IASP). Participating hospitals have to pay a moderate annual fee for the services provided by PAIN OUT (5). The German partner project, QUIPS, is run by the societies of German anesthesiologists and surgeons. Using registries and benchmarking tools like PAIN OUT or QUIPS makes possible to improve quality of treatment for postoperative pain within a realistic and reproducible process. The Aim of this presentation is: a) to report on a successful quality improvement initiative in the field of gynaecology b) to describe the PAIN OUT project c) to address key issues of change management The Dep. of Gynaecology of Jena University Hospital evaluated 4 different strategies to reduce postoperative pain in three different surgeries (laparoscopic gynaecologic surgery, caesarean section and breast surgery) using the PAIN OUT questionnaire. Implementation of new strategies was performed sequentially in time after assessing a baseline of outcome quality of postoperative pain management. First of all gynaecological laparoscopies were evaluated and used a pilot porcedure. The study cohort (n=168) received additionally to standard pain management a port-site (PS) infiltration with ropivacaine prior to incision and intraperitoneal (IP) ropivacaine instillation at the end of surgery. Quality of pain management improved dramatically. Intensity of movement-related pain was significantly reduced (p= .001) from 5.3 (SD 2.2) to 4.4 (SD 2.4) in the study cohort. A similar reduction (p=.007) from 2.6 (SD 1.7) to 2.1 (SD 1.8) was registered for minimal pain after operation. These results were achieved although number of patients who required opioids decreased from 58% to 38% (p = .001). Demanded dose of rescue opioid (piritramide) in the study cohort was lower (p = .035) with 6.5 mg (SD 4.9) versus 8.7 mg (SD 6.6) and demanded later (p =.001) with 4.3 hours after surgery vs. 3.1 hours. Patients in study cohort experienced less nausea (p=.046), had less sleep disturbancies and were significantly more satisfied with pain management (p < .001). To our knowledge, this is the largest prospective study using this application of LA combining preventiv PS and IP use for standardized major and minor gynecological laparoscopic surgery. Since pain after laparoscopy supposedly has a multifactorial origin combining pain-reducing techniques could achieve better results. However, although wound and portside infiltration as well as IP instillation of LA is known and recommended since decades, it is rarely used consequently in clinical practice (6). Using PAIN OUT for this evaluation was helpful in three aspects: convincing all stakeholders that there was a chance for improvement, demonstrating effectiveness of the implemented strategies and consolidating the new strategies as new standards. PAIN OUT turned out to be a practicable instrument for valid process and outcome data assessment in clinical practice. However, apart from medical issues, it was challenging to get the whole team relevant for pain management (surgeons, anesthesiologists, theatre and ward nurses) convinced that processes has to be changed. Therefore, we set up a formal change management approach, consisting of education,
Annals of Surgical Oncology, 2008
Background: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which ... more Background: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which the long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive approach used in our institution over the last 5 years. Methods: Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted in complete surgical cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m 2) in 2 L/m 2 of D5W at 43°C during 30 min. Ronnett's histologic classification was used for tumor grading. Results: From February 2003 to March 2007, 38 patients with PC arising from the appendix underwent laparotomy with curative intent. Mean follow-up was 23 months. Twenty-three patients received HIPEC but ten patients could not have complete cytoreductive surgery and received no HIPEC. Five patients with a negative second-look surgery also received no HIPEC. Three-year overall survival (OS) was 100% for the negative second-look patients, 86% for the HIPEC patients, and 29% for the unresectable patients (P = 0.0098). Three-year disease-free survival (DFS) was 49% for the HIPEC patients. Histologic grade was a prognostic factor with regard to DFS for the HIPEC patients (P = 0.011). There was one postoperative mortality. The overall major (grade III-V/V) complication rate for treated patients was 39%, including intra-abdominal abscess (22%), hemorrhage (18%), and anastomotic leak (9%). Conclusion: Although these results are preliminary, this therapeutic approach seems both feasible and safe in selected patients.
Scientific Reports
Effective perioperative pain management is essential for optimal patient recovery after surgery a... more Effective perioperative pain management is essential for optimal patient recovery after surgery and reduces the risk of chronification. However, in clinical practice, perioperative analgesic treatment still needs to be improved and data availability for evidence-based procedure specific analgesic recommendations is insufficient. We aimed to identify procedures related with high pain scores, to evaluate the effect of higher pain intensity on patients and to define patient and intervention related risk factors for increased pain after standard gynaecological and obstetrical surgery. Therefore, we performed a prospective cross-sectional study based on the German registry for quality in postoperative pain (QUIPS). A cohort of 2508 patients receiving surgery between January 2011 and February 2016 in our tertiary referral centre (university departments of gynaecology and obstetrics, respectively) answered a validated pain questionnaire on the first postoperative day. Maximal pain intensit...
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2014
Journal of Clinical Medicine
Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This st... more Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This study investigated postoperative pain after CS using patient-related outcomes (PROs) to identify risk factors for severe pain. The secondary outcome was to evaluate the influence of surgery indication (primary CS (PCS) vs. urgent CS (UCS)). This multi-center, prospective cohort study included data submitted to the pain registry “quality improvement in postoperative pain treatment” (QUIPS) between 2010 and 2020. In total, 11,932 patients were evaluated. Median of maximal pain was 7.0 (numeric rating scale (NRS) 0 to 10); 53.9% suffered from severe pain (NRS ≥ 7), this being related to impairment of mood, ambulation, deep breathing and sleep, as well as more vertigo, nausea and tiredness (p < 0.001). Distraction, relaxation, mobilization, having conversations, patient-controlled analgesia (PCA) and pain monitoring were shown to be protective for severe pain (p < 0.001). Maximal pain in...
Journal of Orthopaedic Surgery and Research
Background Insufficient pain control after lower limb arthroplasty results in delayed recovery an... more Background Insufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA). Methods All patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir. Results The analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], ...
Poorly managed postoperative pain may prolong length of stay, cause postoperative complications, ... more Poorly managed postoperative pain may prolong length of stay, cause postoperative complications, diminishes quality of life, and causes needless suffering. Severe post-operative pain is a risk factor for developing chronic pain which may increase economic costs and has a negative impact on patient and family quality of life (1). Thus, optimizing management of pain is both humane and cost effective. Nevertheless, management of post-operative pain remains unsatisfactory worldwide. Despite the availability of high-quality guidelines and advanced pain management techniques acute post-operative pain management is still not satisfactory (2). In gynaecology and obstetrics, hysterectomies and caesarean sections belong to the most frequent and rather painful surgeries (3, 4). One reason for the described deficits is the fact that most clinicians lack of valid information on the quality of their pain management because data on processes and outcomesif it all-are not collected in a standardized way. Moreover, even if quality deficits are identified, there is often considerable resistance towards change of daily practices. The PAIN OUT (Improvement in Postoperative Pain Outcome) is a multinational quality improvement and research project that provides a unique and user-friendly web-based information system. It aims to improve treatment of patients with post-operative pain by means of standardised data acquisition, analysis of quality and process indicators, and feed back and benchmarking. The project focusses on patient-reported outcomes, using the short International Pain Outcome questionnaire which is validated in more than 10 languages. From 2009-2012, it was funded by European Commission's 7th Framework Programme. Since 2013, PAIN OUT is being continued in cooperation with professional societies, e.g. the International Association for the Study of Pain (IASP). Participating hospitals have to pay a moderate annual fee for the services provided by PAIN OUT (5). The German partner project, QUIPS, is run by the societies of German anesthesiologists and surgeons. Using registries and benchmarking tools like PAIN OUT or QUIPS makes possible to improve quality of treatment for postoperative pain within a realistic and reproducible process. The Aim of this presentation is: a) to report on a successful quality improvement initiative in the field of gynaecology b) to describe the PAIN OUT project c) to address key issues of change management The Dep. of Gynaecology of Jena University Hospital evaluated 4 different strategies to reduce postoperative pain in three different surgeries (laparoscopic gynaecologic surgery, caesarean section and breast surgery) using the PAIN OUT questionnaire. Implementation of new strategies was performed sequentially in time after assessing a baseline of outcome quality of postoperative pain management. First of all gynaecological laparoscopies were evaluated and used a pilot porcedure. The study cohort (n=168) received additionally to standard pain management a port-site (PS) infiltration with ropivacaine prior to incision and intraperitoneal (IP) ropivacaine instillation at the end of surgery. Quality of pain management improved dramatically. Intensity of movement-related pain was significantly reduced (p= .001) from 5.3 (SD 2.2) to 4.4 (SD 2.4) in the study cohort. A similar reduction (p=.007) from 2.6 (SD 1.7) to 2.1 (SD 1.8) was registered for minimal pain after operation. These results were achieved although number of patients who required opioids decreased from 58% to 38% (p = .001). Demanded dose of rescue opioid (piritramide) in the study cohort was lower (p = .035) with 6.5 mg (SD 4.9) versus 8.7 mg (SD 6.6) and demanded later (p =.001) with 4.3 hours after surgery vs. 3.1 hours. Patients in study cohort experienced less nausea (p=.046), had less sleep disturbancies and were significantly more satisfied with pain management (p < .001). To our knowledge, this is the largest prospective study using this application of LA combining preventiv PS and IP use for standardized major and minor gynecological laparoscopic surgery. Since pain after laparoscopy supposedly has a multifactorial origin combining pain-reducing techniques could achieve better results. However, although wound and portside infiltration as well as IP instillation of LA is known and recommended since decades, it is rarely used consequently in clinical practice (6). Using PAIN OUT for this evaluation was helpful in three aspects: convincing all stakeholders that there was a chance for improvement, demonstrating effectiveness of the implemented strategies and consolidating the new strategies as new standards. PAIN OUT turned out to be a practicable instrument for valid process and outcome data assessment in clinical practice. However, apart from medical issues, it was challenging to get the whole team relevant for pain management (surgeons, anesthesiologists, theatre and ward nurses) convinced that processes has to be changed. Therefore, we set up a formal change management approach, consisting of education,
Annals of Surgical Oncology, 2008
Background: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which ... more Background: Peritoneal carcinomatosis (PC) arising from the appendix is a rare disease for which the long-term prognosis is poor. The aim of this study was to evaluate the results of an aggressive approach used in our institution over the last 5 years. Methods: Data from all patients with PC arising from the appendix were prospectively collected and analyzed. Treatment consisted in complete surgical cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin (460 mg/m 2) in 2 L/m 2 of D5W at 43°C during 30 min. Ronnett's histologic classification was used for tumor grading. Results: From February 2003 to March 2007, 38 patients with PC arising from the appendix underwent laparotomy with curative intent. Mean follow-up was 23 months. Twenty-three patients received HIPEC but ten patients could not have complete cytoreductive surgery and received no HIPEC. Five patients with a negative second-look surgery also received no HIPEC. Three-year overall survival (OS) was 100% for the negative second-look patients, 86% for the HIPEC patients, and 29% for the unresectable patients (P = 0.0098). Three-year disease-free survival (DFS) was 49% for the HIPEC patients. Histologic grade was a prognostic factor with regard to DFS for the HIPEC patients (P = 0.011). There was one postoperative mortality. The overall major (grade III-V/V) complication rate for treated patients was 39%, including intra-abdominal abscess (22%), hemorrhage (18%), and anastomotic leak (9%). Conclusion: Although these results are preliminary, this therapeutic approach seems both feasible and safe in selected patients.
Scientific Reports
Effective perioperative pain management is essential for optimal patient recovery after surgery a... more Effective perioperative pain management is essential for optimal patient recovery after surgery and reduces the risk of chronification. However, in clinical practice, perioperative analgesic treatment still needs to be improved and data availability for evidence-based procedure specific analgesic recommendations is insufficient. We aimed to identify procedures related with high pain scores, to evaluate the effect of higher pain intensity on patients and to define patient and intervention related risk factors for increased pain after standard gynaecological and obstetrical surgery. Therefore, we performed a prospective cross-sectional study based on the German registry for quality in postoperative pain (QUIPS). A cohort of 2508 patients receiving surgery between January 2011 and February 2016 in our tertiary referral centre (university departments of gynaecology and obstetrics, respectively) answered a validated pain questionnaire on the first postoperative day. Maximal pain intensit...
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2014