RESUMO
OBJECTIVE: The repercussions of ischemia-reperfusion and inflammatory response to surgical injury may compromise the return of physiologic processes in video-laparoscopic surgeries. Dexmedetomidine, as an adjuvant drug in general anesthesia, alters the neuroinflammatory reaction, provides better clinical outcomes in the perioperative period, and may reduce the excessive use of chronic medication in patients with a history of addiction. This study evaluated the immunomodulatory potential of dexmedetomidine on perioperative organ function in video-laparoscopic cholecystectomy patients. METHODS: There were two groups: Sevoflurane and Dexmedetomidine A (26 patients) vs. Sevoflurane and Saline 0.9% B (26 patients). Three blood samples were collected three times: 1) before surgery, 2) 4-6h after surgery, and 3) 24h postoperatively. Inflammatory and endocrine mediators were protocolized for analysis. Finally, hemodynamic outcomes, quality upon awakening, pain, postoperative nausea and vomiting, and opioid use were compared between groups. RESULTS: We have demonstrated a reduction of Interleukin 6 six hours after surgery in group A: 34.10 (IQR 13.88-56.15) vs. 65.79 (IQR 23.13-104.97; p = 0.0425) in group B. Systolic blood pressure, diastolic blood pressure, and mean arterial pressure was attenuated in group A in their measurement intervals (p < 0.0001). There was a lower incidence of pain and opioid consumption in the first postoperative hour favoring this group (p < 0.0001). We noticed better quality upon awakening after the intervention when comparing the values of peripheral oxygen saturation and respiratory rate. CONCLUSIONS: Dexmedetomidine provided anti-inflammatory benefits and contributed to postoperative analgesia without the depressive side effects on the respiratory and cardiovascular systems commonly observed with opioids. TRIAL REGISTRATION: Immunomodulatory Effect of Dexmedetomidine as an Adjuvant Drug in Laparoscopic Cholecystectomies, NCT05489900, Registered 5 August 2022-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05489900?term=NCT05489900&draw=2&rank=1.
Assuntos
Colecistectomia Laparoscópica , Dexmedetomidina , Humanos , Dexmedetomidina/efeitos adversos , Analgésicos Opioides/uso terapêutico , Sevoflurano/uso terapêutico , Estudos Prospectivos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/induzido quimicamente , Analgésicos/uso terapêutico , Colecistectomia Laparoscópica/efeitos adversos , Cirurgia Vídeoassistida , Método Duplo-CegoRESUMO
Postoperative pain is one of the main negative symptoms resulting from surgery and the use of new methods to control this symptom is of ever-increasing relevance. Opioid-sparing strategies, such as multimodal analgesia, are trends in this scenario. Pregabalin is a well-established treatment for neuropathic pain; however, it is still controversial in the surgical context for postoperative analgesia. This study investigated the effect of pregabalin on postoperative analgesia in patients undergoing abdominal hysterectomy. It is a prospective, randomised, double-blind, placebo-controlled clinical trial. Female patients undergoing abdominal hysterectomy were randomised to use pregabalin (group P1), 300 mg orally 2 h before surgery, or identical placebo pills (group P0). The main outcome includes the postoperative pain index by visual analogue scale (VAS) and McGill's pain questionnaire. Secondary outcomes include opioid consumption and the presence of adverse effects. A value of p < 0.05 was used to reject type I error. Fifty-five patients were randomised amongst the groups. Patients in group P1 had lower pain rates by VAS scale, both at rest and in active motion, than group P0. In McGill's questionnaire, patients from group P1 also had lower pain rates (12 × 28.5). There was approximately twice as much opioid consumption amongst patients in group P0. Regarding side effects, there was a difference between the two groups only for dizziness, being more incident in group P1. This study suggests that pregabalin is an important adjuvant drug in treating postoperative pain in patients with abdominal hysterectomy.
Assuntos
Analgesia , Analgésicos Opioides , Humanos , Feminino , Pregabalina/uso terapêutico , Estudos Prospectivos , Analgésicos/uso terapêutico , Histerectomia/efeitos adversos , Histerectomia/métodos , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/induzido quimicamente , Método Duplo-CegoRESUMO
Palliative care involves patients with a high incidence of chronic pain and inadequate treatment related to opioid abuse. In terminal patients, the side effects of opioids may result in lower quality of life due to their deleterious immunosuppression and gastrointestinal effects. In our routine clinical practice, we consider the ultrasound-guided PENG block as a palliative analgesic technique to improve end-of-life care to terminal patients.
Assuntos
Analgesia , Bloqueio Nervoso , Osteossarcoma , Analgesia/métodos , Analgésicos Opioides/uso terapêutico , Humanos , Bloqueio Nervoso/métodos , Osteossarcoma/induzido quimicamente , Osteossarcoma/tratamento farmacológico , Dor Pós-Operatória/induzido quimicamente , Dor Pós-Operatória/tratamento farmacológico , Cuidados Paliativos , Qualidade de VidaRESUMO
BACKGROUND: An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. The hypothesis was that adding five recently described intravenous and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. METHODS: In a double-blinded fashion, 78 patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n = 39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, intravenous dexamethasone, and a single injection adductor canal block or (2) a study group (n = 39) that received the same set of analgesic treatments plus five additional interventions: local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative intravenous dexmedetomidine and ketamine, and postoperatively, one additional intravenous dexamethasone bolus and two additional adductor canal block injections. The primary outcome measure was 24-h cumulative opioid consumption after surgery and secondary outcomes were other analgesics, patient recovery, functional outcomes, and adverse events. RESULTS: Opioid consumption was not different between groups at 24 h (oral morphine equivalents, mean ± SD; study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], -5.6 mg [-2.7 to 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25 of 39 [64.1%] vs. 13 of 39 [33.3%]; P = 0.010). CONCLUSIONS: In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single-shot adductor canal block and dexamethasone, the addition of five analgesic interventions-local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intravenous dexmedetomidine, intravenous ketamine, an additional intravenous dexamethasone dose, and repeated adductor canal block injections-failed to further reduce opioid consumption or pain scores or to improve functional outcomes after total knee arthroplasty.
Assuntos
Artroplastia do Joelho , Dexmedetomidina , Ketamina , Bloqueio Nervoso , Analgésicos/uso terapêutico , Analgésicos Opioides , Anestésicos Locais , Artroplastia do Joelho/efeitos adversos , Dexametasona/uso terapêutico , Dexmedetomidina/uso terapêutico , Humanos , Ketamina/uso terapêutico , Morfina , Bloqueio Nervoso/efeitos adversos , Dor Pós-Operatória/induzido quimicamente , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controleRESUMO
OBJECTIVE: Prevention and management of postoperative endodontic pain is a common challenge for the endodontists. This systematic review was conducted to evaluate the efficacy and safety of medicament therapeutic protocols in the prevention and management of endodontic pain. METHODS: A literature search was undertaken in MEDLINE, Cochrane Library, LILACs, and SciELO, for articles published until December 2017, without year restriction and written only in English. An additional search was performed in the references of the retrieved studies. Study eligibility criteria, participants, and interventions: The inclusion criteria were randomised clinical trials that evaluated the use of medications to prevent or control moderate to severe pain in adult patients, using a visual analog scale as a tool for pain measurement. The primary outcome evaluated was the reduction of pain scores. The second outcome evaluated was the need for additional analgesia and the occurrence of adverse events. STUDY APPRAISAL AND SYNTHESIS METHODS: The quality assessment of the included studies was performed following the Jadad scale to measure the likelihood of bias in pain research reports. RESULTS: After removing duplicates and excluding the studies that did not meet the selection criteria, ten studies were included tin the systematic review. Among these studies, five studies administered the medications before the endodontic procedures and five studies after. These studies evaluated non-opioid analgesics (acetaminophen), opioid analgesics (tramadol and codeine), nonsteroidal anti-inflammatories (ibuprofen, flurbiprofen, ketorolac tromethamine, etodolac, tenoxicam, and naproxen), steroidal anti-inflammatory (prednisolone) or the association of medications to prevent or control postoperative pain. It was possible to establish a significant relationship between the use of additional analgesics and periapical diagnosis. Adverse events were not observed when the administration occurred before the endodontic procedure. When it was administered after the procedure, adverse reactions were reported in 2 of 3 trials included in the analysis. LIMITATIONS: A restricted number of randomised clinical trials were found, and the difference in the methodology of the studies did not meet the definition of a systemic treatment protocol for prevention or control of postoperative pain. CONCLUSION: Nonsteroidal anti-inflammatory drugs are the most common medicament to prevent and control postoperative pain, with ibuprofen being the most investigated. There is a significant association between the use of additional analgesics and periapical diagnoses.
Assuntos
Analgésicos não Narcóticos , Tramadol , Adulto , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , Anti-Inflamatórios não Esteroides/uso terapêutico , Humanos , Dor Pós-Operatória/induzido quimicamente , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Tramadol/uso terapêuticoRESUMO
BACKGROUND AND OBJECTIVES: Fentanyl addition is a common practice when administering spinal anesthesia. Intrathecal fentanyl has been associated to increased postoperative pain and increase morphine consumption, but considered to be related to acute opioid tolerance. This prospective, randomized, blind study evaluates the effect of intrathecal fentanyl in the development of secondary hyperalgesia, measured with Von Frey filaments, in patients undergoing anterior cruciate ligament repair. METHODS: 46 patients having anterior cruciate ligament repair, received intrathecal hyperbaric bupivacaine 13.5 mg with fentanyl 20 mcg or no fentanyl addition. Light touch pain threshold was measured with von Frey filaments before anesthesia, at 6 and 24 hours post anesthesia in the non-operated thigh and in the forearm. Visual analogue pain scores and morphine consumption were also measured at the same time. RESULTS: Baseline thresholds to mechanical stimuli were similar in both groups. In the forearm, analysis showed a decreased threshold for the non-fentanyl group at 24 h p = 0.036. In the lower extremity, control and treatment group showed lower thresholds (secondary hyperalgesia) p = 0.002 but no difference between them p = 0.795. VAS score and morphine consumption did not differ among groups. CONCLUSIONS: Spinal fentanyl added to hyperbaric bupivacaine showed no evidence of an augmented state of hyperalgesia after ACL repair, neither by pain threshold modification nor clinical outcomes. On the contrary, at 24 h, fentanyl may have a protective effect at levels above the spinal block.
ANTECEDENTES Y OBJETIVOS: El uso de fentanilo es una práctica común en la administración de anestesia espinal. Su aplicación se ha asociado a un aumento del dolor post operatorio y a un aumento en el uso de morfina; por otro lado, se ha vinculado a una tolerancia aguda a opioides. El siguiente estudio prospectivo, randomizado y ciego, evalúa los efectos del fentanilo intratecal en la aparición de hiperalgesia secundaria, medida a través de filamentos Von Frey, en pacientes operados de ligamento cruzado anterior. METODOLOGÍA: Se incluyeron a 46 pacientes operados de ligamento cruzado anterior (LCA) con una dosis intratecal de bupivacaína hiperbárica de 13,5 mg; con y sin la adición de fentanilo de 20 mcg. Se midió el umbral del dolor mecánico, a través de filamentos Von Frey, antes de la anestesia, a las 6 y 24 horas postanestesia en el muslo no operado y en el antebrazo. Al mismo tiempo, se midió la puntuación del dolor en la escala verbal numérica (EVN) y el consumo de morfina. RESULTADOS: Los umbrales basales ante la estimulación mecánica resultaron similares en ambos grupos. En el antebrazo, el análisis mostró una disminución del umbral en el grupo de pacientes sin fentanilo, a las 24 h, p = 0,036 comparado con uso de fentanilo. En el muslo, el grupo control y tratamiento mostró umbrales más bajos (hiperalgesia secundaria) p = 0,002; no obstante, no se mostraron diferencias entre ellos. No se mostraron diferencias entre las puntuaciones de la EVN y el consumo de morfina en los dos grupos. CONCLUSIÓN: No hay evidencia que la adición de fentanilo espinal, a la dosis de bupivacaína hiperbárica, haya contribuido a un aumento en la hiperalgesia tras la reparación del LCA, medido por la modificación del umbral del dolor, ni en los resultados clínicos. Al contrario a las 24 h fentanilo puede tener un efecto protector de la hiperalgesia secundaria sobre el nivel del bloqueo espinal.
Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Adulto Jovem , Fentanila/efeitos adversos , Reconstrução do Ligamento Cruzado Anterior , Hiperalgesia/induzido quimicamente , Analgésicos Opioides/efeitos adversos , Raquianestesia , Dor Pós-Operatória/induzido quimicamente , Bupivacaína/administração & dosagem , Fentanila/administração & dosagem , Método Duplo-Cego , Estudos Prospectivos , Limiar da Dor , Analgésicos Opioides/administração & dosagemRESUMO
BACKGROUND AND OBJECTIVE: Pleurodesis is one of the best methods of controlling malignant pleural effusions (MPE), a distressing complication of metastatic disease. In recent studies of a wide range of pleural diseases, iodopovidone was used as a sclerosing agent for pleurodesis and demonstrated good results with low morbidity. The aim of this study was to evaluate the efficacy and safety of iodopovidone pleurodesis in MPE. METHODS: A retrospective analysis was performed on patients with MPE who underwent pleurodesis at our institution between 2005 and 2008. All patients underwent instillation of 20 mL of 10% iodopovidone, 80 mL of normal saline and 2 mg/kg of lidocaine through a chest tube, which was clamped for 2 h. The tube was removed when the daily output of fluid was <200 mL. Data on the requirement for additional pleural procedures, adverse events and survival were collected. RESULTS: Sixty-one pleurodesis procedures were performed in 54 patients. No procedure-related mortality was observed. Adverse events occurred after 11 (18%) pleurodesis procedures. The most frequent complication was mild thoracic pain that occurred immediately after 10 (16.4%) procedures, and one patient developed pleural empyema that was treated with drainage and antibiotics. A success rate of 98.4% was observed. Except for the patient who developed pleural empyema, none of the other patients had recurrences of pleural fluid or required additional pleural procedures during the follow-up period (mean of 5.6 months). CONCLUSIONS: Iodopovidone pleurodesis was successful and was associated with only a few minor complications. It appears to be a good option for the management of recurrent MPE.
Assuntos
Derrame Pleural Maligno/tratamento farmacológico , Pleurodese/métodos , Povidona-Iodo/administração & dosagem , Adulto , Idoso , Antibacterianos/uso terapêutico , Drenagem , Empiema Pleural/tratamento farmacológico , Feminino , Humanos , Lidocaína/uso terapêutico , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/induzido quimicamente , Dor Pós-Operatória/tratamento farmacológico , Pleurodese/efeitos adversos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Postoperative analgesia may be complicated by the occurrence of acute opiate tolerance and hyperalgesia. We present the case of a patient who underwent gynecological surgery that was complicated by intense pain in the immediate postoperative period. The pain was attributed to the development of acute opiate tolerance caused by the brief infusion of a high dose of remifentanil. The opiate tolerance was complicated by tactile hyperalgesia at the site of the surgical wound. Pain management with the usual dose of nonsteroidal anti-inflammatory drugs associated with a high dose of morphine (50 mg administered in less than 2 hours) produced no analgesic or adverse effects. The pain was finally brought under control by epidural perfusion of ropivacaine and fentanyl and subsequently maintained with multimodal analgesia.
Assuntos
Amidas/uso terapêutico , Analgesia Epidural , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Fentanila/uso terapêutico , Hiperalgesia/induzido quimicamente , Morfina/uso terapêutico , Dor Pós-Operatória/induzido quimicamente , Piperidinas/efeitos adversos , Acetaminofen/administração & dosagem , Acetaminofen/uso terapêutico , Doenças dos Anexos/cirurgia , Amidas/administração & dosagem , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Resistência a Medicamentos , Tolerância a Medicamentos , Feminino , Fentanila/administração & dosagem , Humanos , Hiperalgesia/tratamento farmacológico , Histerectomia , Cetorolaco/administração & dosagem , Cetorolaco/uso terapêutico , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Remifentanil , RopivacainaRESUMO
In a double blind, placebo-controlled trial, we have assessed the effects of pre-operative anxiolysis on postoperative pain scores in 112 ASA I-II women, aged 18-65 years, scheduled to undergo total abdominal hysterectomy. Subjects were randomly allocated to receive either oral diazepam 10 mg (n=56) or placebo (n=56) pre-operatively. Postoperative anxiety, pain scores, analgesic consumption, and sedation were evaluated at several time points during the first 24 h following surgery. Postoperative pain scores were found to be significantly higher in the diazepam group. Trait and state anxiety showed a significant effect on pain scores, independent of the treatment group. No difference was found between the groups in morphine consumption, but there was a significant reduction in morphine consumption with time.
Assuntos
Ansiolíticos/efeitos adversos , Diazepam/efeitos adversos , Histerectomia , Dor Pós-Operatória/induzido quimicamente , Pré-Medicação/efeitos adversos , Adolescente , Adulto , Idoso , Analgésicos Opioides/administração & dosagem , Ansiedade/prevenção & controle , Sedação Consciente , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Pessoa de Meia-Idade , Morfina/administração & dosagem , Medição da Dor , Dor Pós-Operatória/tratamento farmacológicoRESUMO
Se estudiaron 15 pacientes de ambos sexos, sometidos a cirugía electiva y de urgencia, a los cuales se les administró Buprenorfina 0.3 mg diluidos en 9 ml de solución fisiológica por vía epidural a nivel de L2-L3, para manejo de analgesia postoperatoria. Se utilizó la escala visual análoga de 10 cm (EVA) para medir la intesidad del dolor antes y después de la administración de Buprenorfina por vía epidural. Se realizó registro de signos vitales, previos a la administración de Buprenorfina y una hora después. Se analizó la incidencia de náuseas, vómito y sedación, así como la duración del efecto analgésico con una dosis única de 0.3 mg. El alivio del dolor fue del 88.5 por ciento (p<0.001) la analgesia se mantuvo en promedio 8.7 h; se encontró diferencia significativa en los valores de presión arterial, sistólica y diastólica, y en la frecuencia cardiaca (p<0.05). Los efectos secundarios fueron náuseas 20 por ciento, vómito 13 por ciento y sedación leve 26.6 por ciento, concluimos que el uso de Buprenorfina epidural resulta un tratamiento eficaz y seguro para el alivio del dolor postoperatorio