RESUMO
BACKGROUND: This study compared the Macintosh blade direct laryngoscope, Glidescope, C-Mac d-Blade, and McGrath MAC X-blade video laryngoscopes in 2 cadaveric models with severe cervical spinal instability. We hypothesized that the Glidescope video laryngoscope would allow for intubation with the least amount of cervical spine movement. Our secondary endpoints were glottic visualization and intubation success. METHODS: In total, 2 fresh cadavers underwent maximal surgical destabilization from the craniocervical junction to the cervicothoracic junction by a neurosurgical spine specialist, with subsequent neutral positioning of the heads with surgical head fixation devices. On each cadaver, 8 experienced anesthesiologists performed four intubations with the 4 laryngoscopes in random order. Lateral radiographic measurements determined vertebral displacement during intubation. RESULTS: Cervical spine displacements were not significantly different amongst video laryngoscopes. Cormack-Lehane Grade 1 views were achieved with all attempts with each of the 3 video laryngoscopes; intubation attempts with the Macintosh blade achieved only grade 3 or grade 4 views. Intubation was successful every time with a video laryngoscope but only during 1 of 16 intubation attempts with the Macintosh blade. CONCLUSIONS: In a cadaveric model with maximally destabilized cervical spines, cervical spine movement was observed during attempted laryngoscopy using each of 3 video laryngoscopes, although there was no significant difference between the laryngoscopes. Given cervical spine displacement occurred, these video laryngoscopes do not prevent cervical spine motion during laryngoscopy. However, with improved glottic visualization and intubation success, video laryngoscopes are superior to the Macintosh blade in both cervical spine safety and intubation efficacy in the model studied.
Assuntos
Vértebras Cervicais/patologia , Intubação Intratraqueal , Instabilidade Articular/patologia , Laringoscópios , Idoso , Manuseio das Vias Aéreas , Cadáver , Vértebras Cervicais/diagnóstico por imagem , Feminino , Fluoroscopia , Humanos , Instabilidade Articular/diagnóstico por imagem , Laringoscopia , Masculino , Modelos Biológicos , Doenças da Coluna Vertebral/diagnóstico por imagem , Doenças da Coluna Vertebral/patologia , Traumatismos do Sistema Nervoso/patologia , Gravação em VídeoRESUMO
UNLABELLED: Popliteal sciatic nerve block is a commonly used technique for surgery involving the foot and ankle. However, pain can be difficult to control as the local anesthetic block wears off. Therefore, we hypothesized that extending the block by using a continuous infusion of bupivacaine (0.25%) would provide improved pain management and might facilitate the recovery process after foot or ankle surgery. In this randomized, double-blinded, placebo-controlled study, 24 consenting patients undergoing foot or ankle surgery with a standardized general anesthetic technique were studied. Before surgery, a popliteal sciatic nerve block was performed in all patients with an 18-gauge Tuohy epidural needle and a peripheral nerve stimulator. After injection of bupivacaine 0.25% 30 mL and placement of a 20-gauge catheter, patients were randomly assigned to receive either 0.9% saline (control) or bupivacaine 0.25% at a constant rate of 5 mL/h for up to 48 h after surgery. An 11-point verbal rating scale (0 = no pain to 10 = worst pain imaginable) was used to assess the severity of pain. Opioid analgesic use was recorded at specific time intervals after surgery. Follow-up evaluations were performed at 24 h, 48 h, 72 h, and 1 week after surgery to assess pain scores, as well as patient satisfaction with their pain management and quality of recovery, by using a 100-point verbal rating scale (1 = highly dissatisfied to 100 = highly satisfied). In the bupivacaine group, there was a statistically significant reduction in the maximal pain scores (>50%) and in opioid use (>60%) during the postoperative period compared with the control group. Patient satisfaction with postoperative pain management (95 +/- 3 versus 77 +/- 13) and quality of recovery (96 +/- 7 versus 83 +/- 14) was significantly improved in the bupivacaine group (versus control). In addition, 40% of the patients in the bupivacaine group (versus none in the control group) were able to be discharged home on the day of surgery (P = 0.087). In conclusion, a continuous infusion of bupivacaine 0.25% decreased postoperative pain and the need for opioid analgesic rescue medication after orthopedic surgery involving the foot and ankle, leading to improved patient satisfaction and quality of recovery. IMPLICATIONS: A continuous infusion of bupivacaine 0.25% (versus saline) at the popliteal fossa by using a simple elastomeric pump is an effective method of decreasing postoperative pain, reducing the opioid analgesic requirement, and increasing patient satisfaction with pain management after orthopedic surgery involving the foot and ankle. More importantly, the use of the continuous sciatic nerve block in the popliteal fossa facilitated an earlier discharge after lower extremity surgery.
Assuntos
Tornozelo/cirurgia , Pé/cirurgia , Bloqueio Nervoso , Procedimentos Ortopédicos , Dor Pós-Operatória/tratamento farmacológico , Nervo Isquiático , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais , Bupivacaína , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Medição da Dor/efeitos dos fármacos , Complicações Pós-Operatórias/epidemiologia , Estudos ProspectivosRESUMO
BACKGROUND: Nonsteroidal antiinflammatory drugs are commonly administered as part of a multimodal regimen for pain management in the ambulatory setting. This randomized, double-blinded, placebo-controlled study was designed to compare the analgesic effect of oral rofecoxib, a cyclooxygenase-2 inhibitor, and acetaminophen when administered alone or in combination prior to outpatient otolaryngologic surgery. METHODS: A total of 143 healthy outpatients undergoing elective otolaryngologic surgery were assigned to one of four study groups: group 1 = control (500 mg vitamin C); group 2 = 2 g acetaminophen; group 3 = 50 mg rofecoxib; or group 4 = 2 g acetaminophen and 50 mg rofecoxib. The first oral dose of the study medication was taken 15-45 min before surgery, and a second dose of the same medication was administered on the morning after surgery. Recovery times, side effects, and the need for rescue analgesics were recorded. Follow-up evaluations were performed at 24 and 48 h after surgery to assess postdischarge pain, analgesic requirements, nausea, and patient satisfaction with their postoperative pain management and quality of recovery. Peak pain scores and the need for rescue analgesic medication were used as the endpoints for estimating efficacy of the study drugs, while cost to achieve complete satisfaction with analgesia was used in the cost-effectiveness analysis. RESULTS: Premedication with rofecoxib (50 mg) was significantly more effective than either placebo or acetaminophen (2 g) in reducing the peak postoperative pain, the need for analgesic medication, and improving the quality of recovery and patient satisfaction. Moreover, the addition of acetaminophen failed to improve its analgesic efficacy. An expenditure for rofecoxib of 16.76 US dollars (95% confidence interval, 7.89 to 21.03 US dollars) and 30.24 US dollars (95% confidence interval, 5.25 to 54.20 US dollars) would obtain complete satisfaction with pain control in one additional patient who would not have been satisfied if placebo or acetaminophen, respectively, had been administered prior to surgery. CONCLUSIONS: Rofecoxib, 50 mg administered orally, decreased postoperative pain and the need for analgesic rescue medication after otolaryngologic surgery. The addition of 2 g oral acetaminophen failed to improve its analgesic efficacy.
Assuntos
Acetaminofen/economia , Acetaminofen/uso terapêutico , Procedimentos Cirúrgicos Ambulatórios , Analgésicos não Narcóticos/economia , Analgésicos não Narcóticos/uso terapêutico , Anti-Inflamatórios não Esteroides/economia , Anti-Inflamatórios não Esteroides/uso terapêutico , Lactonas/economia , Lactonas/uso terapêutico , Procedimentos Cirúrgicos Otorrinolaringológicos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/economia , Adolescente , Adulto , Idoso , Análise Custo-Benefício , Custos e Análise de Custo , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/efeitos dos fármacos , Satisfação do Paciente , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/prevenção & controle , SulfonasRESUMO
UNLABELLED: Non-opioid analgesics are often used to supplement opioids for the management of perioperative pain. In this randomized, double-blinded, placebo-controlled study, we examined the effects of acetaminophen and a cyclooxygenase type-2 inhibitor, celecoxib, when administered alone or in combination, before elective otolaryngologic surgery in 112 healthy outpatients. Subjects were assigned to 1 of 4 study groups: Group 1, placebo (vitamin C, 500 mg per os [PO]); Group 2, acetaminophen 2000 mg PO; Group 3, celecoxib 200 mg PO; or Group 4, acetaminophen 2000 mg and celecoxib 200 mg PO. All patients received a standardized anesthetic technique. During the postoperative period, pain was assessed using a 10-point verbal rating scale. Recovery times, the need for rescue analgesics, side effects, and patient satisfaction scores were also recorded. The combination of acetaminophen and celecoxib was significantly more effective than placebo in reducing postoperative pain. Celecoxib, when administered alone or in combination with acetaminophen, improved patients' satisfaction with their postoperative analgesia. With the combination of acetaminophen and celecoxib, an additional expenditure of $6.16 would be required to obtain complete satisfaction with postoperative pain management in one additional patient who would not have been completely satisfied if he/she had received the placebo. However, oral celecoxib or acetaminophen alone was not significantly more effective than placebo in reducing postoperative pain when administered before surgery. We conclude that oral premedication with a combination of acetaminophen (2000 mg) and celecoxib (200 mg) was highly effective in decreasing pain and improving patient satisfaction after outpatient surgery. IMPLICATIONS: Oral premedication with a combination of acetaminophen (2000 mg) and celecoxib (200 mg) was effective in decreasing pain and improving patient satisfaction after otolaryngologic surgery. However, acetaminophen (2000 mg) or celecoxib (200 mg) alone was not significantly more effective than placebo in reducing postoperative pain.