Alcoholización de nervios intercostales en el postoperatorio de la cirugía torácica / Alcoholization of the Intercostal Nerves on the Postoperative Period of Thoracic Surgery

Introducción: La cirugía torácica figura entre los procedimientos quirúrgicos más dolorosos. Objetivo: Describir los resultados de la alcoholización de nervios intercostales para analgesia postoperatoria. Métodos: Se realizó un estudio prospectivo, observacional y descriptivo de pacientes tratados quirúrgicamente por afecciones torácicas durante 2018-2019. La muestra incluyó 50 pacientes que cumplieron los criterios de inclusión: operados por el autor principal, mayores de 18 años, acceso intercostal y firmaron el consentimiento informado. Se excluyeron los operados por otros cirujanos o presentaron afectación de la pared torácica. La intensidad del dolor se categorizó en cuatro grupos: leve, moderado, intenso e insoportable, según escala análogo visual. Resultados: Durante la primera noche, predominaron el dolor leve (25/50 por ciento) y moderado (9/18 por ciento). El dolor intenso se presentó en dos (4 por ciento) pacientes y 14(28 por ciento) no necesitaron medicación adicional. Al día siguiente no hubo casos con dolor intenso y solo 9 acusaron dolor moderado. La analgesia peridural solo se utilizó la primera noche y al siguiente día. La tendencia a disminuir el dolor se mantuvo al segundo y tercer día. No hubo casos con dolor insoportable. A largo plazo solo un paciente presentó dolor intenso que necesitó tratamiento con bloqueos. Conclusiones: La alcoholización disminuyó el uso adicional de analgésicos. No hubo complicaciones ni dolor insoportable, por lo que consideramos que este método podría ser una alternativa segura, sobre todo cuando no se dispone de fármacos costosos o personal entrenado en las técnicas modernas de analgesia postoperatoria(AU)

Introduction: Thoracic surgery is among the most painful surgical procedures. Objective: To describe the outcomes of the alcoholization of the intercostal nerves for postoperative analgesia. Methods: A prospective, observational and descriptive study was carried out, with patients treated surgically for thoracic conditions during 2018-2019. The sample included fifty patients who met the inclusion criteria: operated by the corresponding author, older than eighteen years, intercostal access and patients who signed the informed consent. Those operated on by other surgeons or who had chest wall involvement were excluded. Pain intensity was categorized into four groups: mild, moderate, intense and unbearable, according to the analog-visual scale. Results: During the first night, mild (25: 50 percent) and moderate (9: 18 percent) pain predominated. Severe pain occurred in two (4 percent) patients, while 14 (28 percent) did not require any additional medication. The next day, there were no cases of severe pain and only nine reported moderate pain. Epidural analgesia was only used the first night and the next day. The tendency to decrease in pain was maintained on the second and third days. There were no cases with unbearable pain. In the long term, only one patient had severe pain and required, therefore, treatment with blocks. Conclusions: Alcoholization decreased the additional use of analgesics. There were no complications or unbearable pain, a reason why we consider that this method could be a safe alternative, especially when expensive drugs or personnel trained in modern postoperative analgesia techniques are not available(AU)

Meningitis tras técnica combinada raquídea-epidural para analgesia del parto: reporte de un caso / Case report of meningitis after combined spinal-epidural analgesia for labor

La meningitis pospunción es una complicación importante y poco frecuente de la anestesia neuroaxial. Describimos el caso de una paciente que ingresa para inducción del parto. Se realiza técnica espinal-epidural para analgesia del parto. Cursando 48 h de puerperio instala cefalea intensa, fotofobia y fiebre. No focalidad neurológica. Sin rigidez de nuca. Al examen, restos cavitarios que impresionan fétidos. Se plantea endometritis puerperal iniciando tratamiento antibiótico. Dado la persistencia del cuadro clínico se plantea punción lumbar para confirmación diagnóstica mediante análisis de líquido cefalorraquídeo; siendo éste turbio, por lo cual ingresa a cuidados intensivos con diagnóstico de meningitis aguda. Bacterióloga informa a los 10 días que el cultivo desarrolla estreptococo mitis oralis. La importancia esta dada porque la meningitis puede ser potencialmente devastadora si no se realiza un diagnóstico y tratamiento tempranos, existiendo medidas que se pueden adoptar para prevenir esta complicación.

Post-puncture meningitis is an important and rare complication of neuraxial anesthesia. We describe case of patient who is admitted for induction of labor. A spinal-epidural technique is performed for labor analgesia. During 48 hours of puerperium, she installed intense headache, photophobia and fever. No neurological focus. No stiff neck. On physical exam, cavitary remains that appear fetid. Puerperal endometritis arises starting antibiotic treatment. Given the persistence of the clinical picture, lumbar puncture is considered for diagnostic confirmation by analysis of cerebrospinal fluid; This being cloudy, for which he was admitted to Intensive Care with a diagnosis of acute meningitis. Bacteriologist reports 10 days later develops streptococcus mitis oralis. The importance is given because meningitis can be potentially devastating if early diagnosis and treatment is not performed, and there are measures that can be taken to prevent this complication.

Combined spinal-epidural block for labor analgesia. Comparative study with continuous epidural block / Bloqueio combinado raquiperidural para analgesia de parto. Estudo comparativo com bloqueio peridural contínuo

Abstract Introduction: Lumbar epidural block is an effective and routinely used technique for labor pain relief, and the combined spinal-epidural block has the benefit of using lower doses of local anesthetics and rapid onset of analgesia. The objective of this study was to evaluate the effectiveness and safety of two anesthetic techniques: combined spinal-epidural block and continuous epidural block in pregnant women for labor analgesia. Methods: Eighty patients, ASA II and III, with cephalic presentation and cervical dilation between 5 and 6 cm, undergoing labor analgesia, allocated in two groups according to the anesthetic technique: combined spinal-epidural (GI) and continuous epidural (GII). Pain severity before the blockade, time to complete analgesia, degree of motor blockade, time to full cervical dilation, duration of the second stage of labor, pain severity during the 1st and 2nd stage of labor, type of delivery, use of oxytocin during labor, maternal cardiocirculatory and respiratory parameters and adverse events, and neonatal repercussions were recorded. Results: At the time of anesthesia, pain severity was similar in both groups. Pain relief was faster in GI (4.5 ± 1.5 min) when compared to GII (11.6 ± 4.6 min) p = 0.01; pain scores in the first and second stages of delivery were lower in GI (0.9 ± 0.3 and 1.8 ± 0.7, respectively) when compared to GII (1.9 ± 0.6 and 2.2 ± 0.5, respectively), with p = 0.01 only in the first stage of labor; there was need for local anesthetics supplementation in GII; there were more frequent spontaneous deliveries in GI (80% of patients) than in GII (50%) (p = 0.045) and more frequent use of instrumental (p = 0.03) in GII (12 patients) compared to GI (4 patients); the frequency of cesarean deliveries was significantly higher (p = 0.02) in Group II than in Group I, with 4 cases in GI and 8 cases in GII; absence of maternal cardiocirculatory and respiratory changes and neonatal repercussions; more frequent pruritus in GI (10 patients) and (0 patients in GII) (p = 0.02). Conclusion: The combined blockade proved to be effective with better quality of analgesia and greater comfort for pregnant women, constituting a good option for the practice of obstetric analgesia.

Resumo Introdução: O bloqueio peridural lombar constitui técnica eficaz e rotineiramente empregada para alívio da dor do parto e o bloqueio combinado raquiperidural tem como benefícios o emprego de doses menores de anestésicos locais e rápido início de analgesia. O objetivo do estudo foi avaliar comparativamente a eficácia e a segurança de duas técnicas anestésicas: bloqueio combinado raquiperidural e peridural contínua em grávidas submetidas à analgesia de parto. Método: Oitenta gestantes, ASA 2 e 3, apresentação cefálica e dilatação cervical entre cinco e seis centímetros, submetidas à analgesia de parto, distribuídas em dois grupos de acordo com a técnica anestésica: técnica combinada raquiperidural (GI) e peridural contínua (GII). Avaliaram-se: intensidade de dor antes do bloqueio; tempo para completa analgesia; grau do bloqueio motor; tempo para dilatação cervical total; duração do 2° estágio do trabalho de parto; intensidade de dor durante o 1° e o 2° estágio do trabalho de parto; tipo de parto; uso de ocitocina durante trabalho de parto; parâmetros cardiocirculatórios, respiratórios e eventos adversos maternos; repercussões neonatais. Resultados: No momento da anestesia a intensidade de dor era semelhante em ambos os grupos. O alívio da dor foi mais rápido no GI (4,5 ± 1,5 min) quando comparado com o GII (11,6 ± 4,6 min) p = 0,01; os escores de dor no primeiro e segundo estágios de parto foram menores no GI (0,9 ± 0,3) e (1,8 ± 0,7) quando comparados com o GII (1,9 ± 0,6) e (2,2 ± 0,5) com p = 0,01 somente no primeiro estágio de trabalho de parto; houve necessidade de complementação com anestésicos locais no GII; partos espontâneos mais frequentes em GI (80% das pacientes) do que em GII (50%) p = 0,045 e instrumentais mais frequentes (p = 0,03) em GII (12 pacientes) quando comparadas com o GI (quatro pacientes); a frequência de partos cesáreos foi significativamente maior (p = 0,02) no Grupo II do que no Grupo I, quatro casos no GI e oito no GII; ausência de alterações cardiocirculatórias e respiratórias maternas e repercussões neonatais; prurido mais frequente no GI (10 pacientes) e (0 paciente no GII) p = 0,02. Conclusão: O bloqueio combinado mostrou-se eficaz com melhor qualidade de analgesia e maior conforto às gestantes, constitui boa opção para a prática de analgesia obstétrica.

Manejo de la analgesia en el parto / Management of analgesia in childbirth

Esta guía contiene definiciones y etapas del trabajo de parto, aunque no hay un patrón estándar. El trabajo puede dividirse en tres estadios, 1ro trabajo de parto dilataciòn, 2do dilataciòn cervical completa, 3ro nacimiento neonato. la analgesia epidural sus ventajas, alivio completo, menor riesgo, menos riesgo depresión en el feto, menor riesgo depresión de las fuerzas del parto. Indicaciones medicas; Pre eclampsia, afecciones cardiacas, afeciones respiratorias, enfermedades neurológicas crónicas, epilepsia. Contraindicaciones; Rechazo por la paciente, control inadecuado del feto, terapia anticougulante. espina bifida.

Bilateral subdural hematoma secondary to accidental dural puncture / Hematoma subdural bilateral secundário a punção dural acidental / Hematoma subdural bilateral secundario a punción dural accidental

We report the case of a 25-year-old woman, who received epidural analgesia for labor pain and subsequently presented post-dural puncture headache. Conservative treatment was applied and epidural blood patch was performed. In the absence of clinical improvement and due to changes in the postural component of the headache, a brain imaging test was performed showing a bilateral subdural hematoma. The post-dural puncture headache is relatively common, but the lack of response to established medical treatment as well as the change in its characteristics and the presence of neurological deficit, should raise the suspicion of a subdural hematoma, which although is rare, can be lethal if not diagnosed and treated at the right time.

Apresentamos o caso clínico de uma paciente de 25 anos na qual uma técnica peridural foi aplicada durante o trabalho de parto e posteriormente apresentou cefaleia com características de cefaleia pós-punção dural. Foi iniciado tratamento conservador e tampão de sangue peridural. Devido à ausência de melhoria clínica e à mudança do componente postural da cefaleia, decidiu-se fazer um exame de imagem cerebral que demonstrou a presença de hematoma subdural bilateral. A cefaleia pós-punção dural é relativamente frequente, mas a falta de resposta ao tratamento médico instaurado, assim como a mudança em suas características e a presença de foco neurológico, deve levantar a suspeita de presença de um hematoma subdural que, embora infrequente, pode chegar a ser devastador se não for diagnosticado e tratado oportunamente.

Presentamos el caso clínico de una paciente de 25 años de edad, a quien se le realizó una técnica epidural durante el trabajo de parto y posteriormente presentó cefalea con características de cefalea pospunción dural. Se inició tratamiento conservador y se realizó parche hemático epidural. Ante la falta de mejoría clínica y debido al cambio en el componente postural de la cefalea, se decidió realizar una prueba de imagen cerebral que demostró la presencia de hematoma subdural bilateral. La cefalea pospunción dural es relativamente frecuente, pero la falta de respuesta al tratamiento médico instaurado, así como el cambio en sus características y la presencia de focalidad neurológica, deben hacer sospechar la presencia de un hematoma subdural que, aunque infrecuente, puede llegar a ser devastador si no se diagnostica y trata oportunamente.

Epidural catheterization in cardiac surgery: The 2012 risk assessment.

Aims and Objectives: The risk assessment of epidural hematoma due to catheter placement in patients undergoing cardiac surgery is essential since its benefits have to be weighed against risks, such as the risk of paraplegia. We determined the risk of the catheter-related epidural hematoma in cardiac surgery based on the cases reported in the literature up to September 2012. Materials and Methods: We included all reported cases of epidural catheter placement for cardiac surgery in web and in literature from 1966 to September 2012. Risks of other medical and non-medical activities were retrieved from recent reviews or national statistical reports. Results: Based on our analysis the risk of catheter-related epidural hematoma is 1 in 5493 with a 95% confidence interval (CI) of 1/970-1/31114. The risk of catheter-related epidural hematoma in cardiac surgery is similar to the risk in the general surgery population at 1 in 6,628 (95% CI 1/1,170-1/37,552). Conclusions: The present risk calculation does not justify not offering epidural analgesia as part of a multimodal analgesia protocol in cardiac surgery.

Analgesia regional em cuidados intensivos / Regional analgesia in intensive care / Analgesia regional en cuidados intensivos

JUSTIFICATIVAS E OBJETIVOS: A analgesia regional desempenha um papel importante na abordagem multimodal da dor no doente crítico e permite amenizar o desconforto do doente e reduzir os estresses fisiológico e psicológico associados. Ao diminuir as doses de opioides sistêmicos, reduz alguns dos seus efeitos colaterais, como a síndrome de abstinência, possíveis alterações psicológicas e disfunção gastrintestinal. Apesar desses benefícios, seu uso é controverso, uma vez que os doentes em unidades de cuidados intensivos apresentam frequentemente contraindicações, como coagulopatia, instabilidade hemodinâmica e dificuldade na avaliação neurológica e na execução da técnica regional. CONTEÚDO: Os autores apresentam uma revisão sobre analgesia regional em cuidados intensivos, com foco nas principais vantagens e limitações de seu uso no doente crítico, e descrevem as técnicas regionais mais usadas e a sua aplicabilidade nesse contexto.

JUSTIFICATIONS AND OBJECTIVES: regional analgesia plays an important role in multimodal pain management in critically ill patients, minimizing patient discomfort and reducing the associated physiological and psychological stress. Lower doses of systemic opioids reduce some of its side effects, such as withdrawal syndrome, possible psychological changes, and gastrointestinal dysfunction. Despite these benefits, its use is controversial, as patients in intensive care units often have contraindications, such as coagulopathy, hemodynamic instability, and difficulty in neurological assessment and implementation of regional technique. CONTENT: The authors present a review of regional analgesia in intensive care, focusing on the main advantages and limitations of its use in critically ill patients, and describe the most commonly used regional techniques and its applicability.

JUSTIFICATIVA Y OBJETIVOS: La analgesia regional desempeña un rol importante en el abordaje multimodal del dolor en el enfermo crítico y permite amenizar la incomodidad del enfermo y reducir los estréses fisiológico y psicológico asociados. Al disminuir las dosis de opioides sistémicos, se reducen algunos de sus efectos colaterales, como el síndrome de abstinencia, posibles alteraciones psicológicas y disfunción gastrointestinal. A pesar de esos beneficios, su uso es controversial, pues los enfermos en unidades de cuidados intensivos tienen a menudo contraindicaciones, como la coagulopatía, la inestabilidad hemodinámica y la dificultad en la evaluación neurológica y en la ejecución de la técnica regional. CONTENIDO: Los autores presentan aquí una revisión sobre la analgesia regional en cuidados intensivos, concentrándose en las principales ventajas y limitaciones de su uso en el enfermo crítico, y describen las técnicas regionales más usadas y su aplicabilidad en ese contexto.

Headache and seizures after cervical epidural injection in a patient undergoing coronary artery bypass grafting.

Epidural analgesia is widely used in cardiothoracic surgery. Most of the complications associated with epidural analgesia are related to the insertion techniques of epidural catheter. A 68-year-old obese patient posted for coronary artery bypass grafting surgery developed headache followed by seizures after insertion of the thoracic epidural catheter. Magnetic resonance imaging revealed air in the basal cisterns and in the left frontal region. The patient was managed conservatively and the symptoms subsided after 24 h. Later, the patient underwent coronary angioplasty.

Experiencias en analgesia posoperatoria epidural en el Hospital de Las Mujeres Dr. Adolfo Carit Eva / Experiences in postoperative epidural analgesia Hospital Dr. Adolfo Carit Women Eva

Con la utilización de la anestesia neuroaxial en casos quirúrgicos ginecológicos donde su empleo este indicado, se puede utilizar los set de catéter epidural para la aplicación de la misma y aprovechar el procedimiento invasivo para la colocación de un catéter epidural. Este último proporciona una vía de aplicación local para la infusión de protocolos analgésicos principalmente combinaciones de anestésicos locales más un opiáceo...

[Procedural pain assessment after spinal injections of corticosteroid]

Spinal injections of corticosteroid are commonly performed by rheumatologists in their daily practice but little is known about the frequency, the intensity and the management of procedural pain observed in these osteoarticular injections in daily practice. To evaluate the prevalence and intensity of pain caused by spinal injections. In this observational prospective study, data were collected over 6 months, for up to 44 procedures [corticosteroid spinal injection]. Evaluation of the pain was evaluated immediately before and after the injection using Huskisson's visual analogue scale [VAS]. Statistical analysis was carried out in order to compare patients who had suffered from pain whilst undergoing the procedure to those who had not. Data were analyzed for 17 patients [12 female, mean age 53.6 +/- 10.5 years]. Over 50% of patients experienced procedural pain. Significant predictive factors of genesis of the procedural pain were the young age [p=0.022] and the intensity of the initial pain [p < 0.001], while the existence of a co morbidity is rather a protective factor [p = 0.006]. Others factors such us sex, origin, level of studies, socioeconomic conditions, didn't seem to have of effect on the procedural pain. Most patients undergoing spinal injections suffer from procedural pain. Specific research and guidelines for the management of procedural pain related to rheumatologic care should be established to improve the quality of care provided by physicians

Thoracic epidural analgesia for off-pump coronary artery bypass surgery in patients with chronic obstructive pulmonary disease.

The benefits of thoracic epidural analgesia in patients undergoing coronary artery bypass grafting are well documented. However, the literature available on the role of high thoracic epidural analgesia (HTEA) in patients with chronic obstructive pulmonary disease undergoing off-pump coronary artery bypass graft (OPCAB) surgery is scarce. We conducted a randomized clinical trial to establish whether HTEA is beneficial in patients with chronic obstructive pulmonary disease undergoing elective OPCAB surgery. After institutional ethics board approval and informed consent, 62 chronic obstructive pulmonary disease patients undergoing elective OPCAB were randomly grouped into two (n = 31 each). Both groups received general anesthesia (GA), but in the HTEA group patients, TEA was also administered. Standardized surgical and anesthetic techniques were used for both the groups. Pulmonary function tests were performed pre-operatively, 6 h and 24 h post-extubation and on days 2, 3, 4 and 5 along with arterial blood gas analysis (ABG) analysis. Time for extubation (h) and time for oxygen withdrawal (h) were recorded. Pain score was assessed by the 10-cm visual analogue scale. All hemodynamic/oxygenation parameters were noted. Any complications related to the TEA were also recorded. Patients in the HTEA group were extubated earlier (10.8 h vs. 13.5 h, P < 0.01) and their oxygen withdrawal time was also significantly lower (26.26 h vs. 29.87 h, P < 0.01). The VAS score, both at rest and on coughing, was significantly lower in the HTEA group at all times, post-operatively (P < 0.01). The forced vital capacity improved significantly at 6 h post-operatively in the HTEA group (P = 0.026) and remained significantly higher thereafter. A similar trend was observed in forced expiratory volume in the first second on day 2 in the HTEA group (P = 0.024). We did not observe any significant side-effects/mortality in either group. In chronic obstructive pulmonary disease patients undergoing elective OPCAB surgery, HTEA is a good adjunct to GA for early extubation, faster recovery of pulmonary function and better analgesia.

Horner's syndrome after lumbar epidural analgesia during labor

Horner's syndrome is rarely reported after epidural analgesia during labor. The use of Top-Up local anesthetic for controlling labor pain in the first stage of labor, or to dense the block in caesarean deliveries can result in this complication. We reported a cases of Horner's syndrome during epidural analgesia in labor in spite of not giving any Top-Up dose. The case was clinically evident and was successfully managed by stopping the epidural infusion, and reassuring the parturient as well as the family; until the disappearance of the signs and symptoms. The infusion was then restarted, delivery was uneventful and no consequent neurological or psychological problems were noticed after a one-month follow-up

case of unilateral Horner's syndrome diagnosed in retrospect following epidural analgesia during labour and caesarean section

Horner's syndrome is a rare complication of epidural analgesia in labour. Although it is a sign of high sympathetic block, patients are usually haemodynamicaly stable. We report a case of undiagnosed Horner's syndrome complicating epidural analgesia in labour, where a standard dose of local anaesthetic was given for an emergency caesarean section without problems. This may confirm the benign nature of the syndrome

Incidência de depressão respiratória no pós-operatório em pacientes submetidos à analgesia venosa ou peridural com opioides / Incidencia de depresión respiratoria en el postoperatorio en pacientes sometidos a la analgesia venosa o epidural con opioides / The incidence of postoperative respiratory depression in patients undergoing intravenous or epidural analgesia with opioids

JUSTIFICATIVA E OBJETIVOS: A analgesia controlada pelo paciente (PCA), por via venosa ou peridural, é técnica segura e eficaz no tratamento da dor pós-operatória. Todavia, o uso de opioides não é isento de risco, e a depressão respiratória é a complicação mais temida. Os objetivos deste estudo foram descrever a incidência de depressão respiratória associada à analgesia pós-operatória com opioides administrados por via peridural ou venosa e as características dos pacientes que apresentaram a complicação. MÉTODO: Estudo de incidência, retrospectivo, em pacientes operados no Hospital SARAH Brasília entre dezembro de 1999 e dezembro de 2007 e tratados com PCA com opioides por via venosa ou peridural. Foram definidos como casos de depressão respiratória: frequência respiratória < 8 irpm, necessidade do uso de naloxona ou saturação periférica de oxigênio abaixo de 90 por cento. RESULTADOS: Foram avaliados 2790 pacientes, dos quais 635 pacientes receberam PCA venosa e 2155, analgesia peridural. Ocorreram sete casos de depressão respiratória pós-operatória (incidência de 0,25 por cento). Destes, seis pacientes foram tratados com PCA venosa com morfina, enquanto o último recebeu analgesia peridural com fentanil. A média de idade foi de 30,5 ± 24,7 anos; o tempo médio entre o término da anestesia até a ocorrência da depressão respiratória foi de 18,1 ± 26,3 horas. A ocorrência de depressão respiratória foi significativamente mais frequente na PCA venosa com morfina (p = 0,001) e idade menor que 16 anos (p < 0,05). CONCLUSÕES: A incidência de depressão respiratória encontrada foi semelhante à descrita na literatura, sendo mais frequente em crianças e adolescentes, e com PCA venosa.

BACKGROUND AND OBJECTIVES: Intravenous or epidural patient-controlled analgesia (PCA) is a safe and effective technique in the treatment of postoperative pain. However, the use of opioids is not devoid of risks,and respiratory depression represents the most feared complication. The objective of the present study was to describe the incidence of respiratory depression associated with postoperative analgesia with the intravenous or epidural administration of opioids and the characteristics of the patients who developed this complication. METHODS: This is a retrospective, incidence study in patients who underwent surgeries at the Hospital SARAH Brasília from December 1999 to December 2007 and treated with intravenous or epidural PCA with opioids. Respiratory depression was defined as: respiratory rate < 8 bpm, need to use naloxone, or peripheral oxygen saturation below 90 percent. RESULTS: Two thousand seven hundred and ninety patients were evaluated; 635 of those patients received intravenous PCA and 2155 epidural analgesia. Seven patients developed postoperative respiratory depression (0.25 percent). Six of those patients were treated with intravenous PCA with morphine, while the last one received epidural analgesia with fentanyl. Patients had a mean age of 30.5 ± 24.7 years; the mean time between the end of anesthesia and the development of respiratory depression was 18.1 ± 26.3 hours. The incidence of respiratory depression was significantly higher in PCA with intravenous morphine (p = 0.001) and age below 16 years (p < 0.05). CONCLUSIONS: The incidence of respiratory depression was similar to that described in the literature; it is more frequent in children and adolescents, and with intravenous PCA.

JUSTIFICATIVA Y OBJETIVOS: La analgesia controlada por el paciente (PCA), por vía venosa o epidural, es una técnica segura y eficaz en el tratamiento del dolor postoperatorio. Sin embargo, el uso de opioides no está exento de riesgos y la depresión respiratoria es la complicación más temida. Los objetivos de este estudio fueron describir la incidencia de depresión respiratoria asociada a la analgesia postoperatoria con opioides administrados por vía epidural o venosa, y las características de los pacientes que presentaron la complicación. MÉTODO: Estudio de incidencia retrospectiva en pacientes operados en el Hospital SARAH Brasília entre diciembre de 1999 y diciembre de 2007 y tratados con PCA con opioides por vía venosa o epidural. Se definieron como casos de depresión respiratoria, frecuencia respiratoria d" 8 irpm, necesidad del uso de naloxona, o saturación periférica de oxígeno por debajo de un 90 por ciento. RESULTADOS: Fueron evaluados 2790 pacientes, de los cuales 635 pacientes recibieron PCA venosa y 2155, analgesia epidural. Se dieron siete casos de depresión respiratoria postoperatoria (incidencia de 0,25 por ciento). De ellos, seis pacientes fueron tratados con PCA venosa con morfina, mientras que el último recibió analgesia epidural con fentanil. El promedio de edad fue de 30,5 ± 24,7 años; el tiempo medio entre el término de la anestesia hasta el aparecimiento de la depresión respiratoria fue de 18,1 ± 26,3 horas. El aparecimiento de depresión respiratoria fue significativamente más frecuente en la PCA venosa con morfina (p = 0,001) y en una edad menor que 16 años (p < 0,05). CONCLUSIONES: La incidencia de depresión respiratoria encontrada fue similar a la descrita en la literatura, siendo más frecuente en niños y adolescentes con PCA venosa.

Rol de la analgesia y anestesia epidural en cirugía abdominal / The role of epidural anesthesia and analgesia in abdominal surgery

Desde 1980 que la anestesia peridural (AP) se ha propuesto para manejar el dolor postoperatorio, en especial en cirugías abdominales. A pesar de que ésta es percibida por varios autores, como la analgesia ideal para las cirugías abdominales mayores, hay algunos que prefieren la administración de antiinflamatorios no esteroidales o de opiodes por vía periférica, ya sea en bolos, infusión continua o controlados por el paciente (PCA). Si bien esta última provee mejor analgesia y satisfacción que la administración convencional, no ha demostrado mejorar la morbimortalidad quirúrgica, cosa que sí lo ha hecho la AP. Se realiza una revisión de la literatura con el objetivo de analizar los efectos benéficos y adversos de la anestesia peridural en los pacientes sometidos a una cirugía mayor abdominal. Se concluye que el uso de anestesia epidural intraoperatoria y postoperatoria está asociado a una disminución de la incidencia, severidad de las alteraciones fisiológicas perioperatorias y morbilidad postoperatoria.

Effects on mother and fetus of epidural and combined spinal-epidural techniques for labor analgesia / Efeitos maternos e fetais da analgesia de parto pelas técnicas peridural e duplo bloqueio

OBJECTIVE: Epidural (EA) and combined spinal-epidural (CSE) techniques have both been utilized for labor analgesia. This study compared the effects on the mother and newborn of these techniques in labor analgesia and anesthesia. METHODS: Forty pregnant women received epidural analgesia with 15 mL of 0.125 percent ropivacaine (EA group) and 5 µg of sufentanil plus 2.5mg bupivacaine in the subarachnoid space (CSE group). Pain intensity, sensory blockade level, latency time, motor block intensity, labor analgesia duration, epidural analgesia duration, maternal hypotension, and pruritus were evaluated. The newborns were evaluated by Apgar and the neurological and adaptive capacity score (NACS) developed by Amiel-Tison. RESULTS: There were no significant statistical differences between groups for pain scores, latency time, sensory blockade level, and Apgar score. Motor block, labor analgesia duration, and epidural analgesia duration were greater in the CSE group, whose seven mothers had mild pruritus. The NACS were greater in the EA group after half, two, and 24 hours. Ninety five percent of EA group newborns and 60 percent of CSE group newborns were found to be neurologically healthy at the 24 hour examination. CONCLUSION: EA and CSE analgesia relieved maternal pain during obstetric analgesia, but CSE mothers had pruritus and a longer labor. Newborns of mothers who received epidural analgesia showed the best NACS.

OBJETIVO: A peridural (AP) e a técnica de duplo bloqueio (DB) são utilizadas em analgesia para o trabalho de parto. Este estudo comparou os efeitos na mãe e no feto de ambas as técnicas em analgesia e anestesia para o parto. MÉTODOS: Quarenta parturientes ASA I e II receberam por via peridural 15 ml de ropivacaína a 0,125 por cento (grupo AP) e 5 µg de sufentanil com 2,5 mg bupivacaína por via subaracnóidea (grupo DB). Foram avaliados: intensidade de dor, altura do bloqueio sensitivo, tempo de latência, bloqueio motor, duração da analgesia de parto, tempo para a resolução do parto, hipotensão materna e presença de prurido. Os recém-nascidos foram avaliados pelo índice de Apgar e escore da capacidade adaptativa e neurológica (ECAN), método de Amiel-Tison. RESULTADOS: Não houve diferenças significativas entre os grupos na intensidade da dor, no tempo de latência, no nível do bloqueio sensitivo e no índice de Apgar. O bloqueio motor, a duração da analgesia e o tempo para resolução do parto foram maiores no grupo DB, do qual sete parturientes apresentaram prurido leve. ECAN foi maior no grupo AP após meia hora, duas horas e 24 horas. Noventa e cinco por cento dos recém-nascidos do grupo AP e 60 por cento do grupo DB foram considerados neurologicamente vigorosos ao exame de 24 horas. CONCLUSÃO: As duas técnicas mostraram-se eficazes para analgesia do trabalho de parto. As parturientes do grupo DB apresentaram prurido e trabalho de parto mais prolongado. Recém-nascidos de mães que receberam analgesia de parto via peridural apresentaram melhor ECAN.

Comparison of continuous thoracic epidural and paravertebral block for postoperative analgesia after robotic-assisted coronary artery bypass surgery.

Minimally invasive surgery with robotic assistance should elicit minimal pain. Regional analgesic techniques have shown excellent analgesia after thoracotomy. Thus the aim of this study was to compare thoracic epidural analgesia (TEA) technique with paravertebral block (PVB) technique in these patients with regard to quality of analgesia, complications, and haemodynamic and respiratory parameters. This was a prospective randomised study involving 36 patients undergoing elective robotic-assisted coronary artery bypass grafting (CABG). TEA or PVB were administered in these patients. The results revealed no significant differences with regard to demographics, haemodynamics, and arterial blood gases. Pulmonary functions were better maintained in PVB group postoperatively; however, this was statistically insignificant. The quality of analgesia was also comparable in both the groups. We conclude that PVB is a safe and effective technique for postoperative analgesia after robotic-assisted CABG and is comparable to TEA with regard to quality of analgesia.

Patient-controlled epidural analgesia with fentanyl and bupivacaine provides better analgesia than intravenous morphine patient-controlled analgesia for early thoracotomy pain.

BACKGROUND: Intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) were studied in terms of analgesic efficacy, respiratory function and side effects after thoracic surgery for 24h. PCEA using fentanyl and bupivacaine as compared to IVPCA using morphine provides better pain relief both at rest and during coughing and is associated with fewer side effects. AIMS: To compare IVPCA and PCEA in terms of analgesic efficacy, respiratory function and side effects after thoracic surgery. SETTINGS AND DESIGN: Tertiary care teaching hospital. Prospective, randomized and open study. MATERIALS AND METHODS: Thirty ASA-I or II patients undergoing thoracotomy were assigned randomly to receive either IVPCA using morphine or PCEA using fentanyl and bupivacaine combination postoperatively. No background infusion was administered in either group. Postoperative evaluation included pain intensity both at rest and during coughing, degree of sedation, arterial blood gas, forced vital capacity (FVC), peak expiratory flow rate (PEFR), presence of side effects such as nausea/vomiting and pruritus at 0, 2, 8, 12 and 24h. The primary outcome of the study was the percentage of patients with analgesia failure defined as VAS>30 despite three consecutive PCA boluses requiring rescue analgesia with intravenous fentanyl. STATISTICAL ANALYSIS: Data were analyzed using t -test, chi2 test and Mann-Whitney test. RESULTS: Significantly less number of patients required rescue analgesia in PCEA group ( P< 0.05). Pain relief was better both at rest and during coughing ( P< 0.05) in PCEA group as compared to IVPCA. Patients in the PCEA group were less sedated and had fewer incidences of side effects, i.e. nausea/vomiting and pruritus. Postoperative FVC and PEFR were reduced significantly compared to baseline only in IVPCA group ( P< 0.05). CONCLUSION: After thoracic surgery, PCEA using fentanyl and bupivacaine as compared to IVPCA using morphine provides better pain relief both at rest and during coughing and associated with fewer side effects.