RESUMO
UNLABELLED: The optimum induction agent for anesthesia for electroconvulsive therapy (ECT) has been long debated. Ideal agent should be short acting with minimal suppression of seizure potentials. Recent studies have suggested longer seizure duration with etomidate in comparison to propofol, thiopental, and methohexital. The aim of the present meta-analysis was to pool data available from studies comparing systematically the efficacy of etomidate against other induction agents in terms of seizure duration (both electroencephalography (EEG) and motor). METHODS: We searched the PubMed, Embase, and Cochrane registry for trials evaluating etomidate against methohexital, propofol, or thiopental for duration of EEG or motor seizure in patients undergoing ECT. Specific adverse effects reported were also identified. RESULTS: Seventeen trials were identified involving 704, 84, 2491, and 258 setting of ECT using etomidate, methohexital, thiopental, and propofol, respectively. In the etomidate group, pooled EEG seizure duration was longer by 2.23 seconds (95% confidence interval [CI], -3.62 to 8.01; P = 0.456) than methohexital, longer by 17.65 seconds (95% CI, 9.72-25.57; P < 0.001) than propofol, and longer by 11.81 seconds (95% CI, 4.26-19.35; P = 0.003) than thiopental. Pooled motor seizure duration was longer in etomidate group by 1.45 seconds (95% CI, -4.79 to 7.69; P = 0.649) than methohexital, longer by 11.13 seconds (95% CI, 6.64-15.62; P < 0.001) than propofol, and longer by 3.60 seconds (95% CI, 2.15-5.06; P < 0.001) than thiopental. Myoclonus (6 trials) and painful injection (4 trials) were commonest adverse effects with etomidate. CONCLUSIONS: Etomidate is clearly better in terms of seizure duration potential (both motor and EEG) than propofol and thiopental. Superiority/inferiority over methohexital could not be demonstrated with the presently available literature.
Assuntos
Eletroconvulsoterapia/métodos , Etomidato , Hipnóticos e Sedativos , Eletroencefalografia , Humanos , Convulsões/fisiopatologiaRESUMO
Introducción: El calambre del escribano es un trastorno doloroso refractario que suele manifestarse como enfermedad incapacitante tras un período corto de escritura. La terapia convencional con agentes neurogénicos como la carbamazepina muchas veces no beneficia a estos pacientes. En la literatura moderna se ha resaltado el uso de la toxina botulínica en distonías focales, de manera que su uso también podría extrapolarse a los pacientes con espasmo del escribano. Objetivo: Evaluar la eficacia y la seguridad de la toxina botulínica en casos de calambre refractario del escribano. Metodología: Presentamos 2 casos de calambre refractario del escribano. Se evaluó a los pacientes para determinar el grupo de los músculos de la mano que estaban comprometidos. Una vez identificados los músculos se inyectó en ellos la toxina botulínica y se utilizó la respuesta clínica como base para determinar la dosis total requerida. Se hizo seguimiento a los pacientes a fin de evaluar el grado de alivio y cualquier efecto adverso asociado. Resultados: Los 2pacientes presentaron un grado significativo de alivio clínico tras la aplicación de la toxina botulínica. El tiempo de escritura mejoró y los 2 pacientes refirieron un alivio significativo del dolor. En ambos casos fue necesario repetir la inyección después de 3-6 meses, aunque la afección fue menor en cada recaída y fue posible suspenderles la medicación oral. Uno de los pacientes presentó leve debilidad de la mano, que tuvo un impacto clínico menor y revirtió a la normalidad en un lapso de 2-3 semanas. Este hecho no afectó la satisfacción de los pacientes con el tratamiento, considerando que la enfermedad primaria era incapacitante y afectaba el trabajo profesional de todos los días. Conclusión: La toxina botulínica es una alternativa terapéutica segura y eficaz para tratar a los pacientes afectados con calambre refractario del escribano que consulten la clínica de dolor.
Introduction: Writers cramp is a refractory painful disorder, often presenting as a disabling disease while writing for a short duration. The conventional therapy in the form of neurogenic agents such as carbamazepine often fails to benefit these patients. Modern literature has highlighted the used of botulinum toxin in focal dystonisas and hence its use can also be extrapolated in patients of writers cramps. Aim: Evaluating the efficacy and safety of botulinum toxin in refractory writers cramps. Methodology:We present 2 cases of diagnosed refractory writers cramp. These patients were evaluated for group of handmuscles involved. Once themuscles were identified, botulinum toxin was injected into these muscles and clinical response was used to iterate the total dose of botulinum needed. These patients were followed up for degree of relief and any associated adverse effects. Results: Both patients showed significant clinical relief after the use of botulinum toxin. Their writing time improved and both patients reported a significant pain relief. The patients required repeat injection 3-6 months, however with each reoccurrence their ailment decreased and they could be taken off oral medication. Minor clinically insignificant reversible weakness was seen in one patient, which reverted to normal in 2-3 weeks time which did not affect patients satisfaction to treatment, as the primary disease was disabling for daily professional work. Conclusion: Botulinum toxin is a safe and effective therapeutic option for treating patients of refractory writers cramp presenting in the pain clinic.