[Electrophysiological appropriateness technique based on TCM meridian theory for postoperative pain after urethral reconstruction: A real-world study].

OBJECTIVE: To investigate the clinical efficacy of electrophysiological appropriateness technique (EAT) therapy based on the traditional Chinese medicine (TCM) meridian theory in managing postoperative pain after urethral reconstruction surgery. METHODS: Using the real-world study approach, we enrolled 61 male patients undergoing urethral reconstruction and divided them into a control group (n = 30) and an observation group (n = 31), the former receiving patient-controlled intravenous analgesia (PCIA), while the latter PCIA plus EAT at 4 pairs of acupoints (Hegu, Neiguan, Zusanli and Sanyinjiao bilaterally) and the Ashi point, with 100 mg tramadol hydrochloride given orally as remedial analgesia in both groups in case of postoperative Visual Analogue Scale (VAS) score ≥4. We compared the VAS scores at 4, 12, 24 and 48 hours postoperatively, the dose of cumulative fentanyl used at 48 hours, the number of cases needing remedial analgesia, the time to first flatus and the incidence of adverse reactions between the two groups of patients. RESULTS: The VAS scores were markedly lower in the observation than in the control group at 4, 12, 24 and 48 hours after surgery (P < 0.05), with statistically significant differences in time-dependent effect and interactive effect (P < 0.05). Significant reduction was observed in the doses of cumulative fentanyl (P < 0.05) and remedial tramadol analgesia (P < 0.05), time to first flatus (P < 0.05), and incidence of adverse reactions (P < 0.05) in the observation group in comparison with the controls. CONCLUSION: Electrophysiological therapy based on the TCM meridian theory can safely and effectively alleviate postoperative pain after urethral reconstruction, reduce opioid consumption, and decrease adverse events.

Perioperative Analgesic Efficacy of Yamamoto New Scalp Acupuncture for Canine Mastectomy Combined with Ovariohysterectomy: a Randomized, Controlled Clinical Trial.

Background: Yamamoto New Scalp Acupuncture (YNSA) is a therapy based on the stimulation of points on the scalp and applied to treat different states of pain. Objectives: To investigate the analgesic efficacy of YNSA for dogs undergoing radical unilateral mastectomy with ovariohysterectomy. Methods: Twenty-four dogs were randomly distributed into two treatments (n = 12, per group): bilateral stimulation of basic B, D, and E points (YNSA group) and no application of acupuncture (control group). All dogs were sedated with morphine; anesthesia was induced with propofol and maintained with isoflurane. Fentanyl was intraoperatively administered to control cardiovascular responses to surgical stimulation. Postoperative pain was assessed using an interactive visual analog scale (IVAS) and the short-form of the Glasgow Composite Pain Scale (CMPS-SF). Morphine was administered as rescue analgesia. Data were analyzed using t-tests, Fisher's exact test, Mann-Whitney U test, and Friedman test (p < 0.05). Results: Intraoperatively, the number of dogs requiring supplemental analgesic and the number of doses of fentanyl were lower in the YNSA group than in the control group (p = 0.027-0.034). The IVAS pain scores recorded from 0.5 h to 1 h post-extubation in the YNSA group were lower than those in the control group (p = 0.021-0.023). Postoperative rescue analgesia and CMPS-SF pain scores did not differ between the groups. Conclusion: YNSA decreases intraoperative fentanyl requirements and provides minimal postoperative analgesic benefits to dogs undergoing unilateral mastectomy with ovariohysterectomy.

Recent trends in opioid prescriptions in Korea from 2002 to 2015 based on the Korean NHIS-NSC cohort.

OBJECTIVES: Opioids are prescribed to treat moderate to severe pain. We investigated recent trends in opioid (morphine, oxycodone, fentanyl, and hydromorphone) prescriptions using data from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2015. METHODS: The morphine milligram equivalent (MME) was calculated to standardize the relative potency of opioids. The number (cases) or amount (MME) of annual opioid prescriptions per 10,000 registrants was computed to analyze trends in opioid prescriptions after age standardization. Joinpoint regression analysis was conducted to calculate the annual percentage change and average annual percentage change (AAPC). RESULTS: The number (cases) of prescriptions per 10,000 registrants increased from 0.07 in 2002 to 41.23 in 2015 (AAPC, 76.0%; 95% confidence interval [CI], 61.6 to 91.7). The MME per 10,000 registrants increased from 15.06 in 2002 to 40,727.80 in 2015 (AAPC, 103.0%; 95% CI, 78.2 to 131.3). The highest AAPC of prescriptions and MME per 10,000 registrants were observed in the elderly (60-69 years) and in patients treated at general hospitals. Fentanyl prescriptions increased most rapidly among the 4 opioids. CONCLUSIONS: Consumption of opioids greatly increased in Korea over the 14-year study period.

Physical Compatibility of Nafamostat with Analgesics, Sedatives, and Muscle Relaxants for Treatment of Coronavirus Disease 2019.

BACKGROUND: Severe coronavirus disease 2019 (COVID-19) may require continuous administration of analgesics, sedatives, and muscle relaxants. Nafamostat has recently been reported as a therapeutic agent for COVID-19. However, there is a lack of information on the compatibility of nafamostat with the aforementioned drug classes. This study evaluated the physical compatibility of nafamostat with these drug classes. METHODS: Nafamostat was combined with 1-3 target drugs (fentanyl, morphine, midazolam, dexmedetomidine, and rocuronium). Fifteen physical compatibility tests were conducted. Nafamostat was dissolved in 5% glucose solution; the final concentration was 10 mg/mL. All other medications were diluted in 0.9% sodium chloride to obtain clinically relevant concentrations. The power of hydrogen (pH) of all medications was measured during each test. Compatibility tests were conducted with 4 test solutions in which nafamostat and the target drugs were compounded at equal volume ratios (1:1, 1:1:1, or 1:1:1:1). Visual appearance, turbidity, and pH were evaluated immediately after mixing and at 1 and 3 hours. Physical incompatibilities were defined as gross precipitation, cloudiness, appearance of the Tyndall effect, or a turbidity change of ≥0.5 nephelometric turbidity units (NTU) based on nafamostat. RESULTS: The mean pH of nafamostat was 3.13 ± 0.03. The combination of nafamostat, fentanyl, and dexmedetomidine had the highest pH (3.39 ± 0.01; 3 hours after mixing). All drugs were compatible with nafamostat until 3 hours after admixture, with a mean turbidity value of ≤0.03 NTU. CONCLUSIONS: Infusions combining nafamostat with the tested sedatives, analgesics, and muscle relaxants could be safely administered.

Informe diário de evidências COVID-19: busca realizada em 29 de julho de 2020 / COVID-19 daily evidence report: search conducted on July 29, 2020

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 16 artigos e 3 protocolos.

Syringe or mask? Loop electrosurgical excision procedure under local or general anesthesia: a randomized trial.

BACKGROUND: Loop electrosurgical excision procedure may be performed under local anesthesia or general anesthesia, and practice patterns differ worldwide. No randomized head-to-head comparison has been published to confirm or refute either practice. OBJECTIVE: This study aimed to compare loop electrosurgical excision procedure under local anesthesia vs general anesthesia regarding patient satisfaction and procedure-related outcomes such as rates of involved margins, complications, pain, and blood loss. STUDY DESIGN: Consecutive women referred to our colposcopy unit were recruited. Loop electrosurgical excision procedure was performed under local anesthesia with 4 intracervical injections of bupivacaine hydrochloride 0.5% or under general anesthesia with fentanyl, propofol, and a laryngeal mask with sevoflurane maintenance. The primary endpoint was patient satisfaction assessed on the day of surgery and 14 days thereafter using a Likert scale (score 0-100) and a questionnaire. Secondary endpoints included rates of involved margins, procedure-related complications, pain, blood loss, and surgeon preference. Results were compared using nonparametric and chi-square tests. RESULTS: Between July 2018 and February 2020, we randomized 208 women, 108 in the local anesthesia arm and 100 in the general anesthesia arm. In the intention-to-treat analysis, patient satisfaction did not differ between the study groups directly after surgery (Likert scale 100 [90-100] vs 100 [90-100]; P=.077) and 14 days thereafter (Likert scale 100 [80-100] vs 100 [90-100]; P=.079). In the per-protocol analysis, women in the local anesthesia arm had significantly smaller cone volumes (1.11 cm3 [0.70-1.83] vs 1.58 cm3 [1.08-2.69], respectively; P<.001), less intraoperative blood loss (Δhemoglobin, 0.2 g/dL [-0.1 to 0.4] vs 0.5 g/dL [0.2-0.9]; P<.001), and higher satisfaction after 14 days (100 [90-100] vs 100 [80-100]; P=.026), whereas surgeon preference favored general anesthesia (90 [79-100] vs 100 [90-100], respectively; P=.001). All other secondary outcomes did not differ between groups (resection margin status R1, 6.6% vs 2.1% [P=.26]; cone fragmentation, 12.1% vs 6.3% [P=.27]; procedure duration, 151.5 seconds [120-219.5] vs 180 seconds [117-241.5] [P=.34]; time to complete hemostasis, 60 seconds [34-97] vs 70 seconds [48.25-122.25] [P=.08]; complication rate, 3.3% vs 1.1% [P=.59]). In a multivariate analysis, parity (P=.03), type of transformation zone (P=.03), and cone volume (P=.02) and not study group assignment, age, body mass index, and degree of dysplasia independently influenced the primary endpoint. CONCLUSION: Loop electrosurgical excision procedure under local anesthesia is equally well tolerated and offers patient-reported and procedure-related benefits over general anesthesia, supporting the preferred practice in some institutions and refuting the preferred practice in others.

Comparing the insertion and ventilation of laryngeal mask airway according to the patient's head position and muscle relaxation use. A prospective clinical trial.

OBJECTIVES: To assess the insertion and ventilation of the laryngeal mask airway (LMA) classic while using different head positions with or without muscle relaxant. METHODS: This is a double-blind randomized clinical trial. Patients scheduled for ureteral calculus surgery at Shanghai General Hospital, Shanghai, China were recruited between November 2017 and November 2018. A total of 132 adults were consecutively selected. Patients were randomly divided into 4 groups according to head positioning and muscle relaxant use. An 8-cm-high pillow was used to achieve the sniffing position. The insertion time, initial peak pressure (Ppeak), mean pressure (Pmean) of the airway during intermittent positive pressure ventilation (primary endpoint) and fiberoptic score of the LMA position (secondary endpoint) were evaluated via electronic bronchoscopy through the mask bar. All adverse events were recorded. Results: Data were analyzed by ANOVA, 2-way ANOVA, Chi-squared, Cochran-Mantel-Haenszel, and Kruskal-Wallis tests. The insertion time required for the first attempt, fiberoptic score, Ppeak and Pmean did not differ among the groups. However, the incidence of adverse events in groups not using muscle relaxant was higher than in those using muscle relaxant. Conclusion: Use of a sniffing position and muscle relaxant slightly eased the insertion of the LMA but did not affect the fiberoptic score or ventilation parameters. Using a muscle relaxant, but not the sniffing position, reduced the incidence of adverse effects.

Prescription opioid analgesic use in France: Trends and impact on morbidity-mortality.

BACKGROUND: While data from USA and Canada demonstrate an opioid overdose epidemic, very little nation-wide European studies have been published on this topical subject. METHODS: Using a nationally representative sample of the French Claims database (>700,000 patients), the exhaustive nationwide hospital discharge database, and national mortality registry, all patients dispensed at least one prescription opioid (PO) in 2004-2017 were identified, to describe trends in PO analgesic use, shopping behaviour, opioid-related hospitalizations and deaths. Annual prevalence of PO use and shopping behaviour (≥1 day of overlapping prescriptions from ≥2 prescribers, dispensed by ≥3 pharmacies) was estimated. RESULTS: In 2004-2017, the annual prevalence of weak opioid use codeine, tramadol and opium rose by 150%, 123%, and 244%, respectively (p < 0.05). Strong opioid use increased from 0.54% to 1.1% (+104%, p < 0.05), significantly for oxycodone (+1950%). Strong opioid use in chronic noncancer pain rose by 88% (p < 0.05) and 1180% for oxycodone. Opioid shopping increased from 0.50% to 0.67% (+34%, p < 0.05), associated with higher mortality risk HR = 2.8 [95% confidence interval (CI): 1.2-6.4]. Opioid-related hospitalizations increased from 15 to 40 per 1,000,000 population (+167%, 2000-2017), and opioid-related deaths from 1.3 to 3.2 per 1,000,000 population (+146%, 2000-2015). CONCLUSIONS: This study provided a first European approach to a nationwide estimation with complete access to several national registries. In 2004-2017 in France, PO use excluding dextropropoxyphene more than doubled. The increase in oxycodone and fentanyl use, and nontrivial increasing trend in opioid-related morbidity-mortality should prompt authorities to closely monitor PO consumption in order to prevent alarming increases in opioid-related morbidity-mortality. SIGNIFICANCE: In 2004-2017, prescription opioid use in France at least doubled and oxycodone use increased particularly, associated with a nontrivial increase in opioid-related morbidity-mortality. Although giving no indication for an 'opioid epidemic,' these findings call for proper monitoring of opioid use.

A Comparative Study between Transcutaneous Electrical Nerve Stimulation and Fentanyl to Relieve Shoulder Pain during Laparoscopic Gynecologic Surgery under Spinal Anesthesia: A Randomized Clinical Trail.

Background: Traditionally, laparoscopic procedures have been performed under general anesthesia. Spinal anesthesia is an effective alternative to general anesthesia. However, one of the intraoperative complications of performing laparoscopic surgery under spinal anesthesia is shoulder pain. This study aimed to compare the effect of transcutaneous electrical nerve stimulation (TENS) with fentanyl on pain relief in patients who underwent gynecologic laparoscopy under spinal anesthesia. Methods: We conducted a prospective randomized clinical trial from May 2016 to March 2017. A sample of patients who underwent gynecological laparoscopy under spinal anesthesia was recruited. If they had shoulder pain, they randomly received either transcutaneous electrical nerve stimulation (TENS) or 50 mg of fentanyl. Pain intensity was measured using the single item visual analogue scale (VAS-10 cm) immediately before and 5, 10, 20, and 30 minutes after treatment. Also, the effect of higher doses of analgesia on pain relief was analyzed. Results: In all, 80 patients (40 patients in each group) were entered into the study. The mean pain intensity score was 9.02 ± 1.32 in the TENS group and 8.95 ± 1.33 in the fentanyl group at baseline (P = 0.80). Repeated measures analysis of variance indicated that there was no significant difference on overall pain scores between the two treatment groups adjusted for age, BMI, total analgesia used, and baseline pain score (F (1, 74) = 1.44, P = 0.23). The use of analgesic drugs in the TENS group was significantly higher than the fentanyl group (P = 0.01). In addition, we found that nine patients (22.5%) complained of nausea/vomiting in the TENS group compared to thirteen patients (32.5%) in the fentanyl group (P = 0.31). Conclusions: The findings indicated that TENS was not superior to fentanyl for pain relief in laparoscopic surgery. It seems that the correct use of TENS parameters might merit further investigation. This trial is registered with: IRCT2016031216765N3.

Local Anesthetic-Induced Methemoglobinemia During Pregnancy: A Case Report and Evaluation of Treatment Options.

BACKGROUND: Methemoglobinemia is a well-recognized adverse drug reaction related to the use of certain local anesthetic agents. The mainstay of treatment for methemoglobinemia is i.v. methylene blue, along with provision of supplemental oxygen; however, methylene blue is listed as a category X teratogen. This poses an issue should methemoglobinemia develop during pregnancy. CASE REPORT: A 35-year-old, 20-week and 5-day gravid female was transferred from an outpatient oral surgeon's office for hypoxia. She was undergoing extraction of 28 teeth and was administered an unknown, but "large" quantity of prilocaine during the procedure. Given this exposure, the concern was for methemoglobinemia. This was confirmed with co-oximetry, which showed 34.7% methemoglobin. The initial treatment plan was methylene blue; however, this drug is a category X teratogen. Thus, an interdisciplinary team deliberated and decided on treatment with high-dose ascorbic acid and transfusion of a single unit of packed red blood cells. The patient was managed with noninvasive ventilation strategies and a total of 8 g ascorbic acid. She was discharged on hospital day 3 with no obstetric issues noted. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intravenous ascorbic acid appears to be a potential alternative to methylene blue in this patient population. The data surrounding teratogenicity of methylene blue are mostly related to intra-amniotic or intra-uterine administration. In life-threatening cases of methemoglobinemia during pregnancy, the benefits of i.v. methylene blue may outweigh the risks.

Analgesia for Children in Acute Pain in the Post-codeine Era.

BACKGROUND: Acute pain is one of the most common presenting complaints in pediatric patients presenting to the emergency department. Recently, concern about the safety of narcotics such as codeine has sparked a renewed interest in opioids such as morphine and intranasal fentanyl. OBJECTIVES: Consequently, opioids are being increasingly used in the clinical setting. Despite this, there is ample evidence that clinicians are less willing to offer opioids to children compared to adults. METHODS: The reasons for this are multifactorial but nevertheless, the provision of adequate analgesia in children is echoed by a several academic societies as a priority for comprehensive care. To address this mandate, evidence for therapies such as oral morphine, topical analgesia, and intranasal fentanyl is now mounting. RESULT AND CONCLUSIONS: This review will discuss the evidence and effectiveness of analgesia for children with acutely painful conditions in the post-codeine era.

Economic assessment of postoperative pain control strategies for treatment of adult patients with cancer / Avaliação econômica de estratégias para controle da dor pós-operatória para tratamento de pacientes adultos com câncer

Summary Objective: The authors performed an economic assessment of opioids currently being used for control of postoperative pain relating to the surgical treatment of cancer (fentanyl and sufentanil) within the Brazilian Unified Health System (SUS, in the Portuguese acronym). Method: The assessment was based on the perspective of the government, in order to collaborate with the promotion of effectiveness in public policies of health, and to optimize the allocation of public resources into health. A cost-effectiveness analysis was performed using data collected from the Brazilian Unified Health System and information from literature review, in order to build a decision tree on the alternatives for control of postoperative pain related to cancer treatment among adult patients. The outcomes considered were: effectiveness of postoperative analgesia and occurrence of nausea and vomit in the 48 hour period after surgery, and additional 24-hour cycles in patient follow-up. A univariate sensitivity analysis was conducted in order to verify robustness of the model estimated. Results: Literature review showed a limited number of studies directly comparing fentanyl and sufentanil for control of postoperative pain. The adoption of sufentanil (cost = U$ 25.72 / outcome = 1.6 VAS points) was dominant in relation to the use of fentanyl (cost = U$ 32.58 / outcome = 2.6 VAS points). The estimated model showed robustness in relation to changes in the parameters analyzed. Conclusion: Sufentanil presented higher cost-effectiveness ratio in relation to fentanyl for control of postoperative pain in surgeries related to cancer treatment among adult patients in the Brazilian Unified Health System.

Resumo Objetivo: O artigo apresenta uma avaliação econômica de opioides atualmente utilizados no controle de dor pós-operatória relacionada ao tratamento cirúrgico do câncer (fentanil e sufentanil) no contexto do Sistema Único de Saúde. Método: A avaliação baseou-se na perspectiva do governo, de forma a colaborar na promoção da efetividade das políticas públicas de saúde e melhorar a alocação de recursos públicos em saúde. Uma análise custo-efetividade foi realizada a partir de dados coletados no Sistema Único de Saúde e de informações provenientes de revisão da literatura para construção de uma árvore de decisão contendo alternativas para controle de dor pós-operatória relacionada ao tratamento cirúrgico do câncer entre pacientes adultos. Os desfechos considerados foram: efetividade da analgesia pós-operatória e ocorrência de náusea e vômito no período de 48 horas após cirurgia e em ciclos adicionais de 24 horas de seguimento do paciente. Uma análise de sensibilidade univariada foi conduzida para verificar a robustez do modelo estimado. Resultados: Na revisão de literatura, um número limitado de estudos efetuou comparação direta entre fentanil e sufentanil no controle de dor pós-operatória. A adoção de sufentanil (custo = U$ 25,72 / desfecho = 1,6 pontos VAS) foi dominante em relação ao uso do fentanil (custo = U$ 32,58 / desfecho = 2,6 pontos VAS). O modelo estimado demonstrou robustez em relação a mudanças nos parâmetros analisados. Conclusão: O sufentanil apresentou razão custo-efetividade superior em relação ao fentanil no controle de dor pós-operatória em cirurgias relacionadas ao tratamento de câncer entre pacientes adultos no Sistema Único de Saúde.

Anestesia subaracnoidea con dosis variables de bupivacaina con fentanilo, en la resección transuretral de la próstata / Subarachnoid anesthesia with variable doses of bupivacaine with fentanyl in the trans-urethral resection of the prostate

Introducción: en la actualidad se han descrito diversos modelos de raquianestesia con bupivacaína a dosis diferentes, asociadas o no con fentanilo, que proveen de una anestesia segura y eficaz, disminuyen la intensidad de dolor posquirúrgico, preservan la función cognoscitiva, y reduce las complicaciones atribuidas a la lidocaína hiperbárica por neurotoxicidad. Objetivo: evaluar el efecto de bajas dosis de bupivacaína con fentanilo para anestesia subaracnoidea en pacientes sometidos a resección transuretral de próstata. Materiales y Métodos: se realizó un estudio descriptivo cuantitativo, longitudinal, prospectivo en 200 pacientes programados para dicha cirugía e indicación de anestesia subaracnoidea con bupivacaína, los cuales fueron distribuidos de forma aleatoria en cuatro grupo. Resultados: tanto el bloqueo sensitivo como motor fue más rápido en los pacientes de los Grupos B (3,0; 11,2) y (7,1; 8,3), Grupo C (5,0; 9,4) y (6,2; 9,4) y Grupo D (6,1; 8,3) y (4,7; 10,9); mientras que el Grupo A fue de (6,0; 8,5) y (9,9; 11,7), respectivamente. Se observó que en la totalidad de los pacientes de los Grupos C y D se obtuvo anestesia de buena calidad. Conclusiones: la administración intratecal de 7,5 mg de bupivacaina con 25 µg de fentanilo produjo anestesia satisfactoria, disminuyó el periodo de latencia, mantuvo mejor estabilidad hemodinámica, prolongó la analgesia postoperatoria y se asoció a menor incidencia de complicaciones peri operatorias (AU).

Introduction: currently, several models of spinal anesthesia with bupivacaine in different doses, associated or not to fentanyl, have been described providing a safe and efficacious anesthesia, reducing the intensity of the postsurgical pain, preserving the cognitive function, and reducing the complications attributed to hyperbaric lidocaine due to its neurotoxicity. Aim: to assess the effect of low doses of bupivacaine with fentanyl as subarachnoid anesthesia in patients undergoing a prostate trans-urethral resection. Materials and Methods: a prospective, longitudinal, quantitative, descriptive study was carried out in 200 patients programmed for that kind of surgery and with the indication of subarachnoid anesthesia through bupivacaine; they were randomly distributed in four groups. Outcomes: both, the sensory block and the motor one were faster in the patients of the Group B (3,0; 11,2) and (7,1; 8,3), Group C (5,0; 9,4) and (6,2; 9,4) and Group D (6,1; 8,3) and (4,7; 10,9); while in the patients of the Group A they were (6,0; 8,5) y (9,9; 11,7) respectively. It was observed a good quality anesthesia in all the patients of the Groups C and D. Conclusions: the intrathecal administration of 7,5 mg of bupivacaine with 25 µg of fentanyl produced a satisfactory anesthesia, reduced the latency period, kept a better hemodynamic stability up, extended the post-surgery analgesia and was associated to fewer incidences of perioperative complications (AU).

Anestesia subaracnoidea con dosis variables de bupivacaina con fentanilo, en la resección transuretral de la próstata / Subarachnoid anesthesia with variable doses of bupivacaine with fentanyl in the trans-urethral resection of the prostate

Introducción: en la actualidad se han descrito diversos modelos de raquianestesia con bupivacaína a dosis diferentes, asociadas o no con fentanilo, que proveen de una anestesia segura y eficaz, disminuyen la intensidad de dolor posquirúrgico, preservan la función cognoscitiva, y reduce las complicaciones atribuidas a la lidocaína hiperbárica por neurotoxicidad. Objetivo: evaluar el efecto de bajas dosis de bupivacaína con fentanilo para anestesia subaracnoidea en pacientes sometidos a resección transuretral de próstata. Materiales y Métodos: se realizó un estudio descriptivo cuantitativo, longitudinal, prospectivo en 200 pacientes programados para dicha cirugía e indicación de anestesia subaracnoidea con bupivacaína, los cuales fueron distribuidos de forma aleatoria en cuatro grupo. Resultados: tanto el bloqueo sensitivo como motor fue más rápido en los pacientes de los Grupos B (3,0; 11,2) y (7,1; 8,3), Grupo C (5,0; 9,4) y (6,2; 9,4) y Grupo D (6,1; 8,3) y (4,7; 10,9); mientras que el Grupo A fue de (6,0; 8,5) y (9,9; 11,7), respectivamente. Se observó que en la totalidad de los pacientes de los Grupos C y D se obtuvo anestesia de buena calidad. Conclusiones: la administración intratecal de 7,5 mg de bupivacaina con 25 µg de fentanilo produjo anestesia satisfactoria, disminuyó el periodo de latencia, mantuvo mejor estabilidad hemodinámica, prolongó la analgesia postoperatoria y se asoció a menor incidencia de complicaciones peri operatorias (AU).

Introduction: currently, several models of spinal anesthesia with bupivacaine in different doses, associated or not to fentanyl, have been described providing a safe and efficacious anesthesia, reducing the intensity of the postsurgical pain, preserving the cognitive function, and reducing the complications attributed to hyperbaric lidocaine due to its neurotoxicity. Aim: to assess the effect of low doses of bupivacaine with fentanyl as subarachnoid anesthesia in patients undergoing a prostate trans-urethral resection. Materials and Methods: a prospective, longitudinal, quantitative, descriptive study was carried out in 200 patients programmed for that kind of surgery and with the indication of subarachnoid anesthesia through bupivacaine; they were randomly distributed in four groups. Outcomes: both, the sensory block and the motor one were faster in the patients of the Group B (3,0; 11,2) and (7,1; 8,3), Group C (5,0; 9,4) and (6,2; 9,4) and Group D (6,1; 8,3) and (4,7; 10,9); while in the patients of the Group A they were (6,0; 8,5) y (9,9; 11,7) respectively. It was observed a good quality anesthesia in all the patients of the Groups C and D. Conclusions: the intrathecal administration of 7,5 mg of bupivacaine with 25 µg of fentanyl produced a satisfactory anesthesia, reduced the latency period, kept a better hemodynamic stability up, extended the post-surgery analgesia and was associated to fewer incidences of perioperative complications (AU).

Anaesthesia modalities during laser photocoagulation for retinopathy of prematurity: a retrospective, longitudinal study.

OBJECTIVES: Laser photocoagulation surgery is a routine treatment for threshold retinopathy of prematurity (ROP). However, little is known about which anaesthesia protocols provide efficient pain control while minimising exposure risk to vulnerable infants. In this study, therefore, we assessed the efficacy and tolerability of multiple anaesthesia techniques used on premature infants during laser therapy. DESIGN AND MAIN OUTCOME MEASURES: Anaesthesia modalities consisted of topical eye drops anaesthesia, general anaesthesia and intravenous fentanyl sedation with mechanical ventilation. Laser treatment efficacy and detailed operative information were retrospectively and consecutively analysed. Cardiorespiratory stability was assessed and compared. The Neonatal Pain Agitation and Sedation Scale (N-PASS) was used to evaluate tolerability in infants that underwent intravenous fentanyl sedation. RESULTS: 97 cases of prematurity were included in this study. In 94/97 (96.9%) cases, vascular proliferation regressed. In the topical anaesthesia groups, the ophthalmologist needed 12-16 min more to complete the treatment. During the 3 postoperative days, topical anaesthesia demonstrated the greatest instability; 4/31 (12.90%) infants in this group suffered from life threatening events requiring resuscitation. The only instability observed in general anaesthesia and fentanyl sedation was attributed to difficulty in extubating within 24 hours after surgery. During laser therapy, the N-PASS score increased to 1.8 in the fentanyl sedation group. CONCLUSIONS: Topical anaesthesia was associated with more cardiorespiratory instability during ROP laser treatment. While general anaesthesia and fentanyl sedation had similar postoperative cardiorespiratory results, the latter demonstrated acceptable pain stress control. However, the difficulty of weaning off mechanical ventilation in some cases after surgery needs to be addressed in future studies.

Economic assessment of postoperative pain control strategies for treatment of adult patients with cancer.

OBJECTIVE: The authors performed an economic assessment of opioids currently being used for control of postoperative pain relating to the surgical treatment of cancer (fentanyl and sufentanil) within the Brazilian Unified Health System (SUS, in the Portuguese acronym). METHOD: The assessment was based on the perspective of the government, in order to collaborate with the promotion of effectiveness in public policies of health, and to optimize the allocation of public resources into health. A cost-effectiveness analysis was performed using data collected from the Brazilian Unified Health System and information from literature review, in order to build a decision tree on the alternatives for control of postoperative pain related to cancer treatment among adult patients. The outcomes considered were: effectiveness of postoperative analgesia and occurrence of nausea and vomit in the 48 hour period after surgery, and additional 24-hour cycles in patient follow-up. A univariate sensitivity analysis was conducted in order to verify robustness of the model estimated. RESULTS: Literature review showed a limited number of studies directly comparing fentanyl and sufentanil for control of postoperative pain. The adoption of sufentanil (cost = U$ 25.72 / outcome = 1.6 VAS points) was dominant in relation to the use of fentanyl (cost = U$ 32.58 / outcome = 2.6 VAS points). The estimated model showed robustness in relation to changes in the parameters analyzed. CONCLUSION: Sufentanil presented higher cost-effectiveness ratio in relation to fentanyl for control of postoperative pain in surgeries related to cancer treatment among adult patients in the Brazilian Unified Health System.

Análisis de costo-efectividad de los medicamentos utilizados para el tratamiento de pacientes con dolor neuropático en Colombia / Cost-effectiveness analysis of drugs used for the treatment of patients with neuropathic pain in Colombia

INTRODUCCIÓN: El análisis de costo-efectividad de ácido tióctico, acetaminofén y tramadol, acetaminofén e hidrocodona, tramadol, amitriptilina, imipramina, valproato, acetaminofén y codeína, buprenorfina, capsaicina, carbamazepina, parches de fentanyl, tapentadol, duloxetina, gabapentina, parches de lidocaína, oxcarbazepina, pregabalina para el tratamiento de pacientes con dolor neuropatico en Colombia, se desarrolla en el marco del mecanismo técnico-científico para la ampliación progresiva del plan de beneficios y la definición de la lista de exclusiones, establecido en el artículo 15 de la Ley 1751 de 2015. Estas tecnologías fueron seleccionadas por la Dirección de Beneficios, Costos y Tarifas del Aseguramiento en Salud del Ministerio de Salud y Protección Social (MinSalud), y remitidas al Instituto de Evaluación Tecnológica en Salud (IETS) para su evaluación. Con respecto a la condición de salud de interés, la asociación internacional para el estudio del dolor (IASP 2011) definió el dolor neuropático como dolor causado por consecuencia directa de una lesión o enfermedad del sistema nervioso somatosensitivo. El mecanismo generador del dolor neuropático se halla en cualquier sitio a lo largo del recorrido de las vías nociceptivas (las vías que conducen la información de tipo doloroso), sin estimular inicialmente a los nociceptores (los receptores de dolor), a diferencia de lo que sucede con el dolor nociceptivo o fisiológico. El dolor neuropático es causado por diversos trastornos que afectan el sistema nervioso central y perifér

Fentanyl in a pectin gel treating breakthrough pain in vertebral compression fracture due to multiple myeloma: A descriptive study of three cases.

Breakthrough pain (BTP) currently represents a challenge for health professionals dedicated to the treatment of pain. In this descriptive 1-year follow-up study on three patients with BTP from vertebral crush, in the context of multiple myeloma, the authors have observed the great either efficacy or tolerability profile of fentanyl pectin nasal spray. The most relevant findings in this study were better adherence to treatment compared to previously opioids and also great personal satisfaction. Because of common pathophysiological mechanism for noncancerous pain of bone origin, these good results could open the door to investigation of the use of this drug in this patient's group.

Effects of a Single-Dose of Pre-Emptive Pregabalin on Postoperative Pain and Opioid Consumption After Double-Jaw Surgery: A Randomized Controlled Trial.

PURPOSE: The effect of a single-dose of pre-emptive pregabalin is still unknown, although it is used as an adjuvant in controlling acute postoperative pain. The purpose of this study was to evaluate the effects of pre-emptive single-dose pregabalin on postoperative acute pain and 24-hour opioid consumption in patients who underwent double-jaw surgery. PATIENTS AND METHODS: Forty patients (18 to 45 yr old; American Society of Anesthesiologists status I to II) for whom elective double-jaw surgery was planned under general anesthesia were included in this study, which had been planned as a prospective, randomized, and double-blinded study. Patients were randomly divided into 2 groups: the pregabalin group (n = 20) was given pregabalin 150 mg orally 1 hour before general anesthesia and the placebo group (n = 20) was given an oral placebo capsule. The groups were administered the routine general anesthesia protocol. Postoperative analgesia was performed intravenously in the 2 groups twice a day with dexketoprofen trometamol 50 mg and patient-controlled analgesia with fentanyl. Postoperative analgesia was evaluated using the visual analog scale (VAS). Fentanyl consumption, additional analgesia requirement, and side-effects were recorded during the first 24 hours after surgery. Descriptive and bivariate statistics were computed, and significance was set at a P value less than .05. RESULTS: Compared with placebo, the VAS score was statistically lower in the pregabalin group during the early postoperative period (P < .05). The 24-hour opioid consumption was significantly higher in the placebo group compared with the pregabalin group (509.40 ± 261.56 vs. 260.10 ± 246.53 µq, respectively; P = .004). In addition, the analgesia requirement was statistically lower in the pregabalin group (P < .05). Nausea or vomiting was observed more often in the placebo group, whereas other side-effects were similar for the 2 groups. CONCLUSION: A single 150-mg dose of pre-emptive pregabalin decreased postoperative opioid consumption in the first 24 hours after double-jaw surgery. Multimodal analgesia techniques that contain pre-emptive analgesia can be used successfully in preventing postoperative pain caused by orthognathic surgery.

Evaluation of the brain anaesthesia response monitor during anaesthesia for cardiac surgery: a double-blind, randomised controlled trial using two doses of fentanyl.

The brain anaesthesia response (BAR) monitor uses a method of EEG analysis, based on a model of brain electrical activity, to monitor the cerebral response to anaesthetic and sedative agents via two indices, composite cortical state (CCS) and cortical input (CI). It was hypothesised that CCS would respond to the hypnotic component of anaesthesia and CI would differentiate between two groups of patients receiving different doses of fentanyl. Twenty-five patients scheduled to undergo elective first-time coronary artery bypass graft surgery were randomised to receive a total fentanyl dose of either 12 µg/kg (fentanyl low dose, FLD) or 24 µg/kg (fentanyl moderate dose, FMD), both administered in two divided doses. Propofol was used for anaesthesia induction and pancuronium for intraoperative paralysis. Hemodynamic management was protocolised using vasoactive drugs. BIS, CCS and CI were simultaneously recorded. Response of the indices (CI, CCS and BIS) to propofol and their differences between the two groups at specific points from anaesthesia induction through to aortic cannulation were investigated. Following propofol induction, CCS and BIS but not CI showed a significant reduction. Following the first dose of fentanyl, CI, CCS and BIS decreased in both groups. Following the second dose of fentanyl, there was a significant reduction in CI in the FLD group but not the FMD group, with no significant change found for BIS or CCS in either group. The BAR monitor demonstrates the potential to monitor the level of hypnosis following anaesthesia induction with propofol via the CCS index and to facilitate the titration of fentanyl as a component of balanced anaesthesia via the CI index.