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The effective analysis of electroencephalography(EEG)data to objectively reflect the changes of nociception has been a hot topic of research in recent years.The incidence of moderate to severe postoperative acute pain remains high.Postoperative acute pain seriously affects patients'physical and psy-chological health,yet there is no objective gold standard for measuring perioperative nociception to guide perioperative analgesia.The results of current studies on the characteristics of EEG changes during nociception are contradictory.This paper presents the EEG characteristics of nociception in order to provide a reference for future research design.
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Introduction@#Perioperative pain is a major problem for patients undergoing surgery. Inadequate pain relief can lead to complications like pneumonia, extended hospital stay, re-admissions and patient dissatisfaction. The aim of this research was to determine adequacy of perioperative pain management on immediate post-operative analgesia for elective Intra-abdominal procedures done under general anaesthesia.@*Method@#This is a retrospective study which involved auditing inpatient folders from the 1st of January to 31st of December, 2015.The inclusion criteria were those between the ages of 18 to 60years who had Elective Intra-abdominalprocedure done under general anesthesia.Each folder was audited for perioperative pain management from surgical and anaesthetic charts and data were entered into a proforma list. EpiInfo 3.1 software and Microsoft Excel Spreadsheetwere used for analysis of the extracted data.@*Results@#159 records met the inclusion criteria but only 127 folders were recovered. 28% of patients recorded pain in the immediate postoperative period. There were more females than males and Total Abdominal Hysterectomies was the most common procedure. The age between 31 to 40 years, reported the most pain. Open cholecystectomy’s procedures recorded the most pain complaints and hernia repairs had the least. Verbal response was the highest pain indicator used and 11% of patients who indicated having some pain went from PARU untreated. There were no records of usage of pain scales in any folder retrieved.@*Discussion@#Pain recording in the recovery unit was heavily dependent on the recovery nurse and the patient. The incidence of immediate postoperative pain from this study group was lower when compared to other studies. This could be due to a lack of documentation or a reflection on how well perioperative pain treatment has been done in Lautoka. @*Conclusion@#Overall management of perioperative pain still needs improvement. The anaesthetic team should seriously look at this problem as Anaesthetists are still unaware of their patients pain. It is highly recommend that the formulation of an Acute Pain Management Protocol for Fiji to ensure that Pain be included as the 5th vital sign.
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Abstract Background: The Brief Measure of Preoperative Emotional Stress (B-MEPS) is a suitable screening tool for Preoperative Emotional Stress (PES). However, personalized decision-making demands practical interpretation of the refined version of B-MEPS. Thus, we propose and validate cut-off points on the B-MEPS to classify PES. Also, we assessed if the cut-off points screened preoperative maladaptive psychological features and predicted postoperative opioid use. Methods: This observational study comprises samples of two other primary studies, with 1009 and 233 individuals, respectively. The latent class analysis derived emotional stress subgroups using B-MEPS items. We compared membership with the B-MEPS score through the Youden index. Concurrent criterion validity of the cut-off points was performed with the severity of preoperative depressive symptoms, pain catastrophizing, central sensitization, and sleep quality. Predictive criterion validity was performed with opioid use after surgery. Results: We chose a model with three classes labeled mild, moderate, and severe. The Youden index points −0.1663 and 0.7614 of the B-MEPS score classify individuals, in the severe class, with a sensitivity of 85.7% (80.1%-90.3%) and specificity of 93.5% (91.5-95.1%). The cut-off points of the B-MEPS score have satisfactory concurrent and predictive criterion validity. Conclusions: These findings showed that the preoperative emotional stress index on the B-MEPS offers suitable sensitivity and specificity for discriminating the severity of preoperative psychological stress. They provide a simple tool to identify patients prone to severe PES related to maladaptive psychological features, which might influence the perception of pain and analgesic opioid use in the postoperative period.
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ABSTRACT BACKGROUND AND OBJECTIVES: Spine diseases have a high annual prevalence and are the main causes of years lived with disability and chronic pain. Among the postoperative analgesic control options, patient-controlled analgesia (PCA) and multimodal analgesia (MMA) have shown good clinical results. This meta-analysis seeks new evidence to help in the treatment of acute postoperative pain in patients undergoing spinal surgery. CONTENTS: The following databases were used: Cochrane Central Register of Controlled Trials, Medline and Embase. Studies that compared two post-surgical analgesic interventions were included; MMA and PCA. The parameters evaluated were: analgesic effect; opioid consumption; length of hospital stay; and adverse effects. Registration of the systematic review protocol: (PROSPERO CRD42023446627). There was no statistical difference when assessing analgesic improvement comparing MMA to PCA (MD -0.12 [-0.41, 0.17] 95%CI with p=0.69). There was a statistical difference, with lower opioid consumption in MMA compared to PCA (MD -3.04 [-3.69, -2.39] 95%CI with p=0.0002). Statistically significant difference regarding length of hospital stay in favor of MMA (MD -13.17 [-16.98, -9.36] 95%CI with p=0.00001), and significantly lower incidence of nausea and vomiting in patients undergoing MMA in compared to PCA (OR 0.26 [0.11, -0.64] 95%CI with p=0.003). CONCLUSION: MMA was equivalent to PCA in the treatment of acute postoperative spinal pain, with the significant clinical advantage and safety of lower amounts of infused opioids, shorter hospital stay and lower incidence of adverse effects.
RESUMO JUSTIFICATIVA E OBJETIVOS: As doenças da coluna apresentam alta prevalência anual e são as principais causas de anos vividos com incapacidade e de cronificação da dor. Dentre as opções de controle analgésico pós-operatória, a analgesia controlada pelo paciente (ACP) e a analgesia multimodal (AMM) apresentam bons resultados clínicos. O objetivo deste estudo foi buscar novas evidências que auxiliem no tratamento da dor aguda no pós-operatório do paciente submetido à cirurgia da coluna. CONTEÚDO: As bases de dados utilizadas: Cochrane Central Register of Controlled Trials, Medline e Embase. Foram incluídos estudos que compararam duas intervenções analgésicas pós-cirúrgicas; AMM e ACP. Os parâmetros avaliados foram: efeito analgésico; consumo de opioide; tempo de internação hospitalar e efeitos adversos. Registro do protocolo de revisão sistemática: (PROSPERO CRD42023446627). Não houve diferença estatística quando avaliadas a melhora analgésica comparando a AMM à ACP (MD -0,12 [-0,41, 0,17] 95%CI com p=0,69). Houve diferença estatística, com menor consumo de opioide na AMM em comparação à ACP (MD -3,04 [-3,69, -2,39] 95%IC com p=0,0002). Diferença estatística significativa com relação ao tempo de permanência hospitalar a favor da AMM (MD -13,17 [-16,98, -9,36] 95%IC com p=0,00001), e incidência significativamente menor de náuseas e vômitos nos pacientes submetidos a AMM em comparação a ACP (OR 0,26 [0,11, -0,64] 95%IC com p=0,003). CONCLUSÃO: A AMM foi equivalente à ACP no tratamento da dor aguda pós-operatória da coluna, com a significativa vantagem clínica e a segurança de menores quantidades de opioides infundidos, menor tempo de internação hospitalar e menor incidência de efeitos adversos.
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Abstract Pain is the most common complaint reported to orthopedists in the outpatient clinic, emergency room, or booth. Numerous publications report the inadequate management of both acute and chronic pain by health professionals. This updated article aims to provide information about musculoskeletal pain, its classification, evaluation, diagnosis, and the multimodal therapeutic approach for each case. For acute pain, adequate control allows for earlier rehabilitation to work and reduces the rates of pain chronification. For chronic pain, the goal is to reduce its intensity and improve the quality of life. Currently, some procedures are increasingly used and aided by imaging tests for diagnostic and therapeutic purposes.
Resumo A dor é a queixa mais comum recebida pelo ortopedista no ambulatório e/ou emergência. Inúmeras publicações relatam o manejo inadequado tanto da dor aguda quanto da dor crônica pelos profissionais da saúde. O objetivo desse artigo de atualização é trazer informações sobre a dor musculoesquelética, sua classificação, avaliação, diagnóstico e abordagem terapêutica multimodal para cada situação. Desta maneira, nas dores agudas seu controle adequado possibilita um trabalho de reabilitação mais precoce, bem como diminui os índices de cronificação da dor. Nas dores crônicas sua abordagem além da diminuição de sua intensidade, visa também melhorar a qualidade de vida. Atualmente alguns procedimentos estão sendo cada vez mais utilizados com auxílio de aparato de imagem com objetivo diagnóstico e terapêutico.
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Humanos , Dor/classificação , Dor/diagnóstico , Dor Aguda/classificação , Dor Musculoesquelética , Manejo da DorRESUMO
Resumen: Introducción: el bloqueo en el plano del músculo erector de la espina (ESPB, por sus siglas en inglés) es un procedimiento seguro, en teoría menos exigente que las técnicas convencionales de anestesia regional torácica. Se utiliza para el tratamiento del dolor agudo y crónico. En la revisión de la literatura, no se encontraron informes de su uso como una técnica única en el dolor agudo de fractura de escápula. Presentación de caso: se reporta un caso clínico de ESPB como técnica experimental para el control del dolor postoperatorio agudo en fracturas de la escápula con aplicación a nivel T2. Se llevó a cabo postoperatorio con disminución de dolor después de 10 minutos de realizado, con una calificación de cero en la escala análoga del dolor. En este caso el ESPB fue realizado en el postoperatorio inmediato, con lo que se logró una disminución total del dolor a los 10 minutos, con posterior control de dolor a las 36 horas. Conclusión: este caso muestra la efectividad de ESPB como técnica experimental para control de dolor postoperatorio en fractura de escápula.
Abstract: Introduction: the erector spine plane block (ESPB) is a safe procedure, technically is less demanding than conventional thoracic regional anesthesia techniques. It is used for the treatment of acute and chronic pain. In the literature review, no reports of its use as a single technique in the acute pain of scapula fracture were found. Case presentation: ESPB is reported in a case as an experimental technique for controlling acute postoperative pain in scapula fractures with an application at the T2 level. It was performed postoperatively with a decrease in pain after 10 minutes and a score of zero on the analog pain scale. In this case, the ESPB was performed in the immediate postoperative period, achieving a total decrease in pain at 10 minutes, with subsequent pain control at 36 hours. Conclusion: this case shows the effectiveness of ESPB as an experimental technique for postoperative pain control in scapula fractures.
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Timely post-operative pain management in elderly patients is critically important. Given their physiological changes and comorbidities, management in this group of patients is different from the rest of the population. Knowledge of potentially inappropriate medications (Beers criteria) is relevant because of the presence of comorbidities in this population. Although acetaminophen continues to be safe, non-steroidal anti-inflammatory agents produce several adverse effects which need to be considered before they are used. On the other hand, opioids continue to be one of the pillars in analgesia, with due consideration of their adverse affects and interactions, and the need for dose adjustments. Adequate postoperative pain management prevents adverse effects and the risk of developing chronic pain.
El manejo oportuno del dolor en la población anciana durante el periodo posoperatorio es de vital importancia. Este grupo de pacientes, dado sus cambios fisiológicos y comorbilidades, requieren un manejo diferente al resto de la población. Es relevante conocer cuáles medicamentos son potencialmente inapropiados para su uso (criterios de Beers) ante las comorbilidades de esta población. Si bien el acetaminofén continúa siendo seguro, los antiinflamatorios no esteroideos causan varios efectos adversos que ameritan consideración antes de su uso; por su parte, los opioides siguen siendo uno de los pilares analgésicos, teniendo en cuenta sus efectos adversos y valorando la necesidad de ajuste de dosis e interacciones. El adecuado manejo del dolor posoperatorio previene desenlaces adversos y el riesgo de cronificación.
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ABSTRACT BACKGROUND AND OBJECTIVES: Pain is a predominant symptom in the postoperative period and expected in any surgical service, being considered as a worldwide problem. Therefore, the aim of this study was to describe and analyze its epidemiological aspects, intensity, and predictors, for better management and predictability. METHODS: This is a quantitative, retrospective and cross-sectional observational study, carried out in a tertiary hospital at Londrina-PR, in which medical records of post-surgical patients who responded to pain scales during their stay in the post-anesthetic recovery room were analyzed. RESULTS: This study found that females are more likely to have postoperative pain and that younger patients are more susceptible, although not significantly. Mild pain predominated at rates greater than 60%, in which spinal blocks and gynecological/obstetric procedures were the most prevalent, in contrast to severe pain, which obtained higher percentages when general anesthesia and orthopedic surgeries were performed. In addition, an equation for predicting severe pain in the immediate postoperative period was obtained, based on the chosen anesthesia and the patient's age. CONCLUSION: Less intense postoperative pain was more prevalent than other intensities, with anesthesia and the type of surgery being possible predictive factors, even if the harbinger of its severity was based on age and the anesthetic method.
RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é um sintoma predominante no pós-operatório e é esperada em qualquer serviço cirúrgico, sendo considerada um problema mundial. Portanto, o objetivo deste estudo foi descrever e analisar seus aspectos epidemiológicos, intensidade e preditores, tendo em vista um melhor manejo e previsibilidade. MÉTODOS: Estudo observacional quantitativo, retrospectivo e transversal, realizado em um hospital terciário no município de Londrina-PR, em que foram analisados prontuários de pacientes pós-cirúrgicos que responderam às escalas de dor durante permanência na sala de recuperação pós-anestésica. RESULTADOS: Esta pesquisa constatou que o sexo feminino possui maior tendência em ter dor pós-operatória e que pacientes mais jovens são os mais suscetíveis, apesar de não apresentarem grande significância. A dor leve predominou com taxas superiores a 60%, sendo que bloqueios espinhais e procedimentos ginecológicos/obstétricos foram os mais prevalentes, em contraste com a dor intensa, que obteve maiores percentuais quando realizadas anestesia geral e cirurgias ortopédicas. Além disso, obteve-se uma equação preditora de dores intensas no pós-operatório imediato, baseada no tipo de anestesia e na idade do paciente. CONCLUSÃO: A dor pós-operatória de menor intensidade foi mais prevalente que as outras intensidades, sendo a anestesia empregada e o tipo de cirurgia possíveis fatores preditores, mesmo que o prenúncio de sua severidade fosse baseado na idade e no método anestésico.
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Introduction: Pain is a very frequent symptom in emergency medicine and the understanding of its epidemio-clinical characters is essential to better manage it. The objective of our work was to describe the epidemiological and clinical characteristics of acute pain in a medical emergency department. Materials and methods: This is a prospective study carried out in the Emergency Reception-Triage Service of the CHU-MA Mahajanga, from October 1, 2018 to September 30, 2019. We recorded the socio-demographic data of the patients as well as the characteristics pains. The variables were analyzed by SPSS 25.0 software. The frequency of painful patients admitted is estimated at 43.5%. The Results: pain has concerned mainly patients from 46 to 60 years old (27.33%), with an average age of 57 years of female gender (61.2%). The group working in the informal sector (65.5%) was the most affected. As for the reasons for admission, it was mainly acute pain (86.3%) due to an excess nociception (97.9%), dominated by medical pathologies with preponderance digestive pathologies (34.5%). Through this study, we were able to see that pain is the most common reason for entering the Conclusion: emergency room. According to our study, it predominates in people of age more advanced and the most frequent causes are medical pathologies.
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SUMMARY OBJECTIVE: This study aimed to evaluate the effectiveness of cryotherapy in elderly patients with rib fractures due to blunt thoracic trauma. METHODS: In this prospective randomized controlled study, geriatric patients were assigned to groups to receive either coolant spray (n=51) or placebo spray (n=50). The visual analog scale scores of all patients were recorded before starting spray application (V0), as well as at 10th (V1), 20th (V2), 30th (V3), 60th (V4), 120th (V5), and 360th (V6) minute. The mean decreases in the visual analog scale scores were calculated. RESULTS: The differences between V0 and V1, V0 and V2, V0 and V3, and V0 and V4 mean visual analog scale scores measured in the coolant spray group were found to be significantly higher (p<0.001). In V1, V2, V3, and V4 measurements, the incidence of "clinical effectiveness" in the coolant spray group was significantly higher than in the placebo group (p=0.001). CONCLUSIONS: Coolant spray therapy can be used as a component of multimodal therapy to provide adequate analgesia due to rib fractures in geriatric patients.
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Objective:To improve the understanding of acute pain after thoracoscopic surgery in patients with early-stage lung adenocarcinoma, to analyze and screen out the independent risk factors that may induce acute postoperative pain. The patients' surgery experience may get improved through the corresponding timely and effective interventions.Methods:We retrospectively reviewed the clinical data of 204 patients with early-stage lung adenocarcinoma who were treated by a single medical team of our center from May 2021 to October 2021, and analyzed the assessment results of acute postoperative pain. Patients were grouped according to the general condition, past medical history, social and spiritual attributes, lesion characteristics, surgical approaches and anesthetic methods. Comparison of proportions of acute postoperative pain between the groups were made, and independent risk factors were identified.Results:A total of 84 males and 120 females were enrolled, with a mean age of(57.9±11.5)years old and a median operation time of 120(110, 145) min. No serious complication or perioperative death occurred in the whole group. Postoperative pain control failed in 76 cases(37.3%), 24 cases(11.8%) suffered from severe postoperative pain, and 33 cases(16.2%) required additional intramuscular injection of strong analgesics after surgery. Those who were younger than 60 years old, with a university degree or above, received two-incision surgery, operated for more than 2 h, received general anesthesia only, or in a state of depression, had significantly higher rates of postoperative acute pain, compared with their respective control groups( P<0.05). The independent risk factors for acute pain after thoracoscopic surgery included age( P=0.002), history of alcoholism( P=0.014), number of incisions( P=0.016), operation time( P=0.010), depression status( P=0.037) and enhanced anesthetic method( P=0.012). Conclusion:A large amount of patients with early-stage lung cancer suffered from acute pain after thoracoscopic surgery, which seriously affected their treatment experience and even quality of life. Young patients with a history of alcoholism and depression status were high-risk groups for postoperative acute pain. Applying Uniportal video-assisted thoracoscopic surgery, reducing the operation time as much as possible, and choosing enhanced analgesic anesthesia represented by epidural block combined with general anesthesia might be effective ways to reduce the probability of acute postoperative pain.
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BACKGROUND: Dystonia is uncommon in Tourette's syndrome, and occipital neuralgia secondary to Tourette's dystonia is more rare, affecting quality of life. Occipital peripheral nerve stimulation (PNS) is an excellent alternative by being adjustable and minimally invasive. Our case demonstrates occipital PNS as an effective option for refractory Tourette's dystonia. CASE PRESENTATION: A thirty-four-year-old male with poorly controlled Tourette's cervical dystonia presented with severe occipital neuralgia. Various medications were prescribed including propranolol and amitriptyline, and bilateral third-occipital nerve rhizotomies and occipital nerve blocks were trialed. Distal nerve blocks at the occipital protuberance were most effective. Therefore, an occipital PNS trial was done, and a PNS was implanted with no complications. Upon follow-up, the patient reported drastic pain reduction. CONCLUSION: Our case illustrates neuromodulation benefits for a rare presentation of refractory occipital neuralgia secondary to Tourette's-related dystonia. Occipital PNS should be considered for refractory cases because it is safe, easy to implant, and effective.
FUNDAMENTO: A distonia é incomum na síndrome de Tourette, e a neuralgia occipital secundária à distonia de Tourette é mais rara, afetando a qualidade de vida. A estimulação do nervo periférico occipital (SNP) é uma excelente alternativa por ser ajustável e minimamente invasiva. Nosso caso demonstra o SNP occipital como uma opção eficaz para a distonia de Tourette refratária. APRESENTAÇÃO DO CASO: Um homem de 34 anos com distonia cervical de Tourette mal controlada apresentou neuralgia occipital grave. Vários medicamentos foram prescritos, incluindo propranolol e amitriptilina, e foram testadas rizotomias bilaterais do nervo terceiro-occipital e bloqueios do nervo occipital. Os bloqueios dos nervos distais na protuberância occipital foram mais eficazes. Portanto, foi feito um ensaio de PNS occipital e um PNS foi implantado sem complicações. Após o acompanhamento, o paciente relatou redução drástica da dor. CONCLUSÃO: Nosso caso ilustra os benefícios da neuromodulação para uma apresentação rara de neuralgia occipital refratária secundária à distonia relacionada a Tourette. O PNS occipital deve ser considerado para casos refratários porque é seguro, fácil de implantar e eficaz.
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Humanos , Masculino , Feminino , Pacientes/classificação , Síndrome de Tourette/complicações , Nervos Periféricos/anormalidadesRESUMO
Abstract In an attempt to improvise the analgesia in patients with femoral fractures, we aimed at depositing local anesthetic deep to anterior psoas fascia (APf) under ultrasound (US) guidance to block lumbar plexus elements which emerge lateral, anterior, and medial to the psoas major muscle. We termed this as circumpsoas block (CPB). Clinical and computed tomography contrast studies revealed that a continuous CPB infusion with a catheter provided a reliable block of the lumbar plexus elements. No adverse were events noted. We conclude that US guided CPB is a reliable technique for managing postoperative pain after surgery of femur fractures.
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Dor Pós-Operatória , Fêmur , Fraturas do Quadril , Plexo Lombossacral , Ultrassonografia , Dor Aguda , Anestesia por ConduçãoRESUMO
Abstract Background: Modified thoracoabdominal nerve block through perichondrial approach is a novel fascial plane block and provides abdominal analgesia by blocking thoracoabdominal nerves. Our primary aim was to evaluate the efficacy of M-TAPA on quality of recovery and pain scores in patients who underwent laparoscopic inguinal hernia repair surgery (Trans Abdominal Pre-Peritoneal approach ‒ TAPP). Methods: Patients with American Society of Anesthesiologists (ASA) physical status I-II aged between 18 and 65 years scheduled for elective TAPP under general anesthesia were enrolled in the study. After intubation, the patients were randomized into two groups: M: M-TAPA group (n = 30) and the control group (n = 30). M-TAPA was performed with total 40 ml 0.25% bupivacaine in the M group. Surgical infiltration was performed in the control group. The primary outcome of the study was the global quality of recovery score, the secondary outcomes were pain scores, rescue analgesic demands, and adverse effects during the 24-h postoperative period. Results: The global quality of recovery scores at 24 h were significantly higher in the M group (p < 0.001). There was a reduction in the median static and dynamic NRS for the first postoperative 8 h in the M group compared to the control group (p < 0.001). The need for rescue analgesia was significantly lower in the M group compared to the control group (13 patients vs. 24 respectively, p < 0.001). The incidence of side effects was significantly higher in the control group (p < 0.001). Conclusion: In our study, M-TAPA increased patient recovery scores, and provided pain relief in patients who underwent TAPP. Register Number: NCT05199922.
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Humanos , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Adulto Jovem , Laparoscopia , Hérnia Inguinal/cirurgia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , BupivacaínaRESUMO
Resumo Objetivo Descrever o processo de implementação de uma intervenção multifacetada de tradução e intercâmbio do conhecimento para melhorar as práticas de manejo da dor, e avaliar a adoção desta intervenção pelos profissionais de saúde durante procedimentos dolorosos em neonatos. Métodos Estudo quase-experimental tipo antes e depois, realizado em uma unidade neonatal. A intervenção Evidence-Based Practice for Improving Quality , norteada pela estrutura conceitual The Promoting Action on Research Implementation in Health Services , foi implementada em duas etapas (preparação e implementação), e a sua adoção foi mensurada por indicadores clínicos relacionados ao manejo da dor, apresentados por meio de estatística descritiva. Resultados Após discussão sobre práticas existentes na unidade que necessitavam de mudança; síntese das evidências científicas atuais; e dados do contexto local; os membros do Conselho de Pesquisa e Prática da unidade elaboraram e implementaram metas coerentes e factíveis para mudança da prática no manejo da dor; selecionaram estratégias de tradução e intercâmbio do conhecimento; determinaram o público-alvo e os indicadores e implementaram as intervenções. Houve uma redução em 32,8% no número de procedimentos dolorosos realizados, e aumento entre 26,6 e 50,7% na utilização das escalas de avaliação da dor e de 25,1% na administração da glicose oral. Conclusão A intervenção multifacetada Evidence-Based Practice for Improving Quality é complexa, e possui processos que demandam conhecimento e habilidades, comprometimento dos diversos atores envolvidos, disponibilidade de tempo e investimento financeiro. Os indicadores analisados mostraram que a intervenção resultou em mudanças positivas na prática clínica no manejo da dor do neonato.
Resumen Objetivo Describir el proceso de implementación de una intervención multifacética de traducción e intercambio de conocimiento para mejorar las prácticas de manejo del dolor y evaluar la adopción de esta intervención por profesionales de la salud durante procedimientos dolorosos en neonatos. Métodos Estudio cuasi experimental tipo antes y después, realizado en una unidad neonatal. Se implementó la intervención Evidence-Based Practice for Improving Quality , norteada por la estructura conceptual The Promoting Action on Research Implementation in Health Services , en dos etapas (preparación e implementación), y su adopción fue medida mediante indicadores clínicos relacionados con el manejo del dolor, presentados por medio de estadística descriptiva. Resultados Después de discutir sobre prácticas existentes en la unidad que necesitaba cambios y realizar una síntesis de las evidencias científicas actuales y de datos del contexto local, los miembros del Consejo de Investigación y Práctica de la unidad elaboraron e implementaron metas coherentes y factibles para cambiar la práctica del manejo de dolor, seleccionaron estrategias de traducción e intercambio de conocimiento, determinaron el público destinatario y los indicadores e implementaron las intervenciones. Hubo una reducción del 32,8 % del número de procedimientos dolorosos realizados y un aumento de 26,6 a 50,7 % de utilización de las escalas de evaluación del dolor y del 25,1 % de la administración de glucosa oral. Conclusión La intervención multifacética Evidence-Based Practice for Improving Quality es compleja y contiene procesos que requieren conocimiento y habilidades, compromiso de los diferentes actores involucrados, disponibilidad de tiempo e inversión financiera. Los indicadores analizados mostraron que la intervención produjo cambios positivos en la práctica clínica del manejo del dolor del neonato.
Abstract Objective To describe the implementation process of a multifaceted knowledge translation and exchange intervention to improve pain management practices, and to evaluate the adoption of this intervention by health professionals during painful procedures in neonates. Methods A quasi-experimental before-and-after study developed in a neonatal unit. The Evidence-Based Practice for Improving Quality intervention guided by the conceptual framework The Promoting Action on Research Implementation in Health Services was implemented in two stages (preparation and implementation). Its adoption was measured by clinical indicators related to pain management presented through descriptive statistics. Results After discussion on existing practices in the unit that needed to be changed, synthesis of current scientific evidence and local context data, members of the unit's Research and Practice Council developed and implemented coherent and achievable goals for the change of practice in pain management, selected knowledge translation and exchange strategies, determined the target audience and indicators, and implemented the interventions. There was a 32.8% reduction in the number of painful procedures performed, an increase of 26.6-50.7% in the use of pain assessment scales and of 25.1% in the administration of oral glucose. Conclusion The multifaceted Evidence-Based Practice for Improving Quality intervention is complex, and has processes that demand knowledge and skills, commitment from the various actors involved, availability of time and financial investment. The analyzed indicators showed that the intervention resulted in positive changes in clinical practice in the management of pain in neonates.
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ABSTRACT Several population studies showed an association between variation in pain sensitivity and genetic polymorphisms located in Prodynorphin (PDYN) and Kappa Opioid Receptor (OPRK1) human genes. We analysed polymorphisms of these two genes to characterise their variation in Argentinian populations, as well as to evaluate their association with acute pain sensitivity. We studied 11 genetic markers in individuals from four locations in Argentina (Ciudad Autónoma de Buenos Aires, La Plata, Resistencia, and Misión Nueva Pompeya), calculated the population parameters, and evaluated the possible association among pain sensitivity, clinical, and genetic variables through a Generalised Estimating Equation model. High linkage disequilibrium was observed in the four populations for both genes, and significant differences were found among frequencies of Argentinian populations and those from other continents reported in the 1000 Genomes Project. Four PDYN gene polymorphisms from 3´ untranslated region and exon 4 showed association with acute pain sensitivity. One genotype of each of these polymorphisms was associated with a higher pain sensitivity, probably related with the activation of the N-methyl-D-aspartate (NMDA) receptors. We found a strong association with acute pain for the following clinical variables: 1) time after surgery, 2) intravenous klosidol supplied every 8 h, and 3) type of incision. Our results highlight the importance of a regional study of genetic variants which influence pain sensitivity and analgesic response.
RESUMEN La asociación entre la sensibilidad al dolor y los polimorfismos que presentan los genes humanos de prodinorfina (PDYN) y receptor opioide kappa (OPRK1) se ha evidenciado en distintos estudios poblacionales. Con el objetivo de caracterizar la variación de estos genes y evaluar su asociación con dolor agudo en la población argentina, analizamos 11 polimorfismos en individuos provenientes de cuatro localidades argentinas (Ciudad Autónoma de Buenos Aires, La Plata, Resistencia, y Misión Nueva Pompeya). Calculamos los parámetros poblacionales y evaluamos la posible asociación entre sensibilidad al dolor, variables clínicas y variables genéticas a través de un modelo de ecuación generalizada de estimación. Se observó alto desequilibrio de ligamiento para ambos genes en las cuatro poblaciones analizadas, y se encontraron diferencias significativas entre las frecuencias de poblaciones argentinas y las reportadas en el Proyecto 1000 Genomes para poblaciones de otros continentes. Cuatro polimorfismos de la región 3´UTR y el exón 4 de PDYN mostraron asociación con la sensibilidad al dolor agudo. En cada uno de estos polimorfismos, un genotipo resultó asociado con alta sensibilidad al dolor, probablemente en relación con la activación de receptores N-metil-D-aspartato (NMDA). Encontramos una fuerte asociación con dolor agudo para las siguientes variables clínicas: 1) tiempo post-cirugía, 2) administración intravenosa de klosidol cada 8 h, y 3) tipo de incisión. Nuestros resultados resaltan la importancia de realizar estudios regionales de variables genéticas que influyen en la sensibilidad al dolor y la respuesta analgésica.
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Background: Nimesulide shows preferential inhibition for the cyclooxygenase-2 (COX-2) enzyme, which blocks the formation of prostaglandins critical in pain and inflammatory pathways. Few studies in the past have reported rare and unpredictable hepatic effects with nimesulide. The present study aimed to evaluate the efficacy and safety of nimesulide/paracetamol (100 mg + 325 mg) fixed-dose combination twice a day for 2 weeks in the management of acute pain in Indian population. Materials and methods: This was a multicenter study, performed on 500 patients, by 24 experienced physicians across India. The primary outcome assessed clinical safety at 2 weeks for mild/serious adverse effects (AEs), change in liver function tests (LFTs), serum bilirubin and alkaline phosphatase levels. The secondary outcomes assessed the clinical effectiveness in reduction of pain at rest and at movement. Results: Analysis of LFT at 2 weeks showed a slight increase (mean change) in the aspartate transaminase {-0.73 [95% confidence interval (CI) -1.54, 0.09; p = 0.081]}, alanine transaminase [-1.73 (95% CI -2.82, -0.64; p = 0.002)], serum bilirubin [-0.02 (95% CI -0.04, -0.001; p = 0.018)] and alkaline phosphatase levels [-1.92 (95% CI -5.84, 2; p = 0.336), not exceeding the normal range. Only one in 500 patients reported AEs. The numerical rating scale (NRS) scores for intensity of pain at rest and at movement at 2 weeks, ?7 days and >7 days were 68.38%, 68.44% and 68.39%; and 65.43%, 64.60% and 66.02%, respectively. An improvement of 96.6% was observed in patient global assessment scale (GAS) and 97.2% in physician GAS. Conclusion: Nimesulide/paracetamol combination was safe, effective and well-tolerated in acute pain conditions and did not lead to clinically significant changes in liver parameters indicating hepatic safety.
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Resumen: Introducción: Las guías actuales para el manejo del dolor en pacientes con adicciones no contemplan el tratamiento del dolor agudo. Objetivo: Describir los esquemas de tratamiento analgésico y la dosis promedio de opioide requerida para control del dolor agudo en pacientes consumidores de sustancias psicoactivas hospitalizados en un Servicio de Traumatología. Material y métodos: Se realizó un estudio descriptivo, retrospectivo y transversal a través de la revisión de expedientes de pacientes con lesión traumática y antecedente de consumo de sustancias que fueron tratados bajo un esquema de analgesia multimodal. Resultados: Se incluyeron 75 pacientes con edad promedio de 32 (± 9.6) años. El opioide indicado con mayor frecuencia fue la buprenorfina en 48% (dosis media 644 μg/24h), seguida de la morfina en 28% (dosis media 20 mg/24h) y tramadol en 24% de los pacientes (dosis media 195 mg/24h). No hubo diferencia estadísticamente significativa (p < 0.05) en el control del dolor entre los tres grupos, excepto que la intensidad del dolor en el grupo de la morfina fue mayor a las 24 horas. Conclusión: Los pacientes tratados con buprenorfina tuvieron mejor control del dolor en comparación con el grupo de morfina, aunque requirieron dosis 40% mayores a las recomendadas para pacientes con trauma.
Abstract: Introduction: Current guidelines for pain management in addiction patients do not address acute pain care. Objective: To describe the analgesic treatment schemes and the average dose of opioid required for the control of acute pain in psychoactive substance-using patients hospitalized in a trauma department. Material and methods: A descriptive, retrospective, and cross-sectional study was carried out by reviewing the records of patients with traumatic injury and a history of substance use who were treated under a multimodal analgesia scheme. Results: 75 patients with a mean age of 32 (± 9.6) years were included. The most frequently prescribed opioid was buprenorphine in 48% (mean dose 644 µg/24h), followed by morphine in 28% (mean dose 20 mg/24h) and tramadol in 24% of patients (mean dose 195 mg/24h). There was not statistically significant difference (p < 0.05) in pain control between the three groups, except that the intensity of pain in the morphine group was greater at 24 hours. Conclusion: The patients treated with buprenorphine had better pain control compared to the morphine group, although doses 40% higher than those recommended for trauma patients were required.
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ABSTRACT BACKGROUND AND OBJECTIVES: Erector spinae plane block is an interfascial plane block used as a tool for management of pain resulting from thoracic and abdominal surgical procedures described in the literature since 2016 and widely used in clinical practice. In the context of the pandemic caused by Sars-CoV-2, multiple pulmonary complications arising from severe viral pneumonia and respiratory failure that required surgical approaches for their investigation and/or treatment were observed. The present study's objective was to present a series of three cases of patients affected by COVID-19 who had pulmonary complications due to infection or exacerbation of previous pulmonary diseases caused by the new coronavirus, in which the continuous fascial plane block was successfully used for postoperative pain management. CASE REPORTS: Three cases of patients with COVID-19 viral pneumonia requiring diagnostic or therapeutic thoracic surgery who underwent erector spinae plane block for perioperative pain management were presented. CONCLUSION: The use of a catheter with continuous infusion of local anesthetic was useful for reducing analgesic rescue and maintaining good postoperative analgesia with no evidence of adverse effects in the presented patients, also allowing acceleration of postoperative recovery and a better outcome for the patients.
RESUMO JUSTIFICATIVA E OBJETIVOS: O bloqueio do plano dos músculos eretores da espinha é um bloqueio do plano interfascial usado como ferramenta para manejo de dor consequente a procedimentos cirúrgicos torácicos e abdominais descrito na literatura desde 2016 e amplamente utilizado na prática clínica. No contexto da pandemia causada pelo Sars-CoV-2, foram observadas múltiplas complicações pulmonares decorrentes de pneumonia viral grave e insuficiência respiratória que demandaram abordagens cirúrgicas para sua investigação e/ou tratamento. O objetivo deste estudo foi apresentar uma série de três casos de pacientes acometidos pela COVID-19 que tiveram complicações pulmonares pela infecção ou exacerbação de doença pulmonar prévia causada pelo novo coronavírus, nos quais o recurso do bloqueio do plano fascial contínuo foi utilizado para manejo de dor pós-operatória com sucesso. RELATO DOS CASOS: Foram apresentados três casos de pacientes acometidos pelo COVID-19 em sua forma de pneumonia viral, para os quais houve necessidade de cirurgia torácica diagnóstica ou terapêutica, e que foram submetidos ao bloqueio do plano dos músculos eretores da espinha para manejo da dor perioperatória. CONCLUSÃO: O uso de cateter com infusão contínua de anestésico local foi útil para a diminuição dos resgates analgésicos e manutenção de boa analgesia pós-operatória sem evidência de efeitos adversos nos pacientes apresentados, possibilitando ainda a aceleração da recuperação pós-operatória e um melhor desfecho para os pacientes.
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ABSTRACT BACKGROUND AND OBJECTIVES: According to the redefinition, acute pain is a somatic experience, with individual perception of physical or existential threat, comprising affective, cognitive and behavioral components. In critically ill patients, pain is a frequent and poorly controlled symptom, causing worse outcomes. The objective of this study was to explore the topic of acute pain in critically ill adult patients, focusing on some aspects of pathophysiology, in addition to updates regarding diagnosis, multimodal therapy and discussion of its control as a marker of good care practice. CONTENTS: A search strategy was performed with the descriptors previously defined in the Pubmed and Cochrane portals, in the period from 2011 to 2021, without a language restriction filter. Acute pain represents a physiological response to a nociceptive stimulus, with high relevance due to its ability to activate complex pathways (inflammatory, hormonal and immune), with systemic repercussions. Pain assessment is often performed using recognized scales, but with limited validation in patients with traumatic brain injury, burns and patients with severe delirium and/or dementia. Studies considering these patients point to the use of new technologies in an attempt to target this diagnosis, such as bedside pupillometry and the use of platforms capable of integrating multiparametric measurements. Regarding therapy, the concept of analgosedation, aiming at prioritizing analgesia in critically ill patients, presents an approach capable of improving clinical outcomes. In addition, there is a preference for multimodal therapy as a good medical practice through the association of different drugs with different mechanisms of no-ciceptive blockade as a strategy to achieve pain control and facilitate the reduction of opioid consumption. CONCLUSION: Due to its systemic effects and prevalence, acute pain is still a relevant problem in intensive care units. New diagnostic methods are being marketed with the aim of targeting this evaluation in complex patients. The approach to acute pain should prioritize the use of multimodal techniques, which present more consistent clinical responses, in addition to reducing the consumption of opioids. The existence of multidisciplinary teams specialized in pain control in the hospital environment is able to assist in difficult cases and help in quality audits.
RESUMO JUSTIFICATIVA E OBJETIVOS: Conforme redefinição, a dor aguda é uma experiência somática, com percepção individual de ameaça física ou existencial, compreendendo componentes afetivos, cognitivos e comportamentais. Em pacientes críticos, a dor representa um sintoma frequente e mal controlado, ocasionando piores desfechos. O objetivo deste estudo foi explorar a temática da dor aguda nos pacientes críticos adultos, com enfoque em alguns aspectos de fisiopatologia, além de atualizações em relação a diagnóstico, terapêutica multimodal e discussão de seu controle como um marcador de boa prática assistencial. CONTEÚDO: Foi realizada estratégia de busca com os descritores previamente definidos nos portais Pubmed e Cochrane, no período de 2011 a 2021, sem filtro de restrição para idioma. A dor aguda representa uma resposta fisiológica a um estímulo nociceptivo, tendo alta relevância por sua capacidade de ativar vias complexas (inflamatórias, hormonais e imunes), com repercussões sistêmicas. A avaliação da dor é frequentemente realizada através de escalas reconhecidas, porém com validação limitada em pacientes com trauma cranioencefálico, queimados e portadores de delirium e/ou demência acentuados. Os estudos considerando esses pacientes apontam para o uso de novas tecnologias na tentativa de objetivar esse diagnóstico, como a pupilometria à beira leito e o uso de plataformas capazes de integrar medidas multiparamétricas. Em relação à terapêutica, o conceito de analgosedação, objetivando priorização de analgesia nos pacientes críticos, apresenta abordagem capaz de melhorar desfechos clínicos. Além disso, há preferência da terapêutica multimodal como boa prática médica através da associação de diferentes fármacos com diversos mecanismos de bloqueio nociceptivo como estratégia para alcançar controle álgico e facilitar a redução do consumo de opioides. CONCLUSÃO: Por seus efeitos sistêmicos e sua prevalência, a dor aguda ainda é problemática relevante nas unidades de terapia intensiva. Novos métodos diagnósticos estão sendo comercializados com a proposta de objetivar essa avaliação em pacientes complexos. A abordagem da dor aguda deve priorizar o emprego de técnicas multimodais, que apresentam respostas clínicas mais consistentes, além de redução no consumo de opioides. A existência de equipes multidisciplinares especializadas no controle da dor no ambiente hospitalar é capaz de auxiliar em casos difíceis e ajudar nas auditorias de qualidade.