Lumbar Neuraxial Ultrasound for Spinal and Epidural Anesthesia: A Systematic Review and Meta-Analysis.

BACKGROUND: This systematic review examines the evidence for preprocedural neuraxial ultrasound as an adjunct to lumbar spinal and epidural anesthesia in adults. METHODS: We searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to June 30, 2014, for randomized controlled trials (RCTs) and cohort studies that reported data answering one or more of the following 3 questions: (1) Does ultrasound accurately identify a given lumbar intervertebral space? (2) Does ultrasound accurately predict the needle insertion depth required to reach the epidural or intrathecal space? (3) Does ultrasound improve the efficacy and safety of spinal or lumbar epidural anesthesia? RESULTS: Thirty-one clinical trials and 1 meta-analysis were included in this review. Data from 8 studies indicate that neuraxial ultrasound can identify a given lumbar intervertebral space more accurately than by landmark palpation alone. Thirteen studies reported an excellent correlation between ultrasound-measured depth and needle insertion depth to the epidural or intrathecal space. The mean difference between the 2 measurements was within 3 mm in most studies. Thirteen RCTs, 5 cohort studies, and 1 meta-analysis reported data on efficacy and safety outcomes. Results consistently showed that ultrasound resulted in increased success and ease of performance. Ultrasound seemed to reduce the risk of traumatic procedures but there was otherwise insufficient evidence to conclude if it significantly improves safety. CONCLUSIONS: There is significant evidence supporting the role of neuraxial ultrasound in improving the precision and efficacy of neuraxial anesthetic techniques. WHAT'S NEW: We know that neuraxial ultrasound is a useful complement to clinical examination when performing lumbar central neuraxial blocks. It provides anatomical information including the depth of the epidural space, the identity of a given intervertebral level, and the location of the midline and interspinous/interlaminar spaces. This information can be used to successfully guide subsequent needle insertion.Since 2010, new data from RCTs and 1 meta-analysis suggest that neuraxial ultrasound increases the success and reduces the technical difficulty of lumbar central neuraxial blocks. Findings from the meta-analysis suggest that neuraxial ultrasound reduces the risk of traumatic procedures, and thus may possibly contribute to the safety of lumbar central neuraxial blocks.

Analgesic effectiveness of dipyrone (metamizol) for postoperative pain after herniorrhaphy: a randomized, double-blind, dose-response study.

BACKGROUND: The efficacy of non-narcotic analgesics is mostly supported by randomized, placebo-controlled trials with no comparison with ordinary practice. Additionally, systematic reviews of these placebo-controlled trials have failed to determine clinically meaningful dose-response effect. METHODS: In this double-blind, randomized trial, patients undergoing elective inguinal, umbilical or epigastric herniorrhaphy under general anesthesia were assigned to receive 15 mg/kg (D15 group) vs. 40 mg/kg (D40 group) of dipyrone intravenously during surgery. The primary outcome was the incidence of moderate to severe pain with movement during the recovery room phase. The secondary outcomes were morphine consumption, incidence of vomiting, and Ramsay score (sedation scale). RESULTS: One hundred sixty-two patients were enrolled and analyzed for the primary and secondary outcomes. Relative to the D15 group, the D40 group showed a lower incidence of moderate to severe pain in the first 30 minutes (61% and 40%; P value < 0.05); lower cumulative morphine consumption during the recovery period (3.85 vs. 2.55 mg, P value < 0.006) as well as a lower incidence of vomiting (15.8% vs. 2.5%, P value < 0.005). In addition, more cases of sedation were recorded in the D15 group than in the D40 group (17 vs. 10 cases). There were no serious adverse effects attributed to dipyrone in either group. CONCLUSION: This trial shows a dose-response effect of 40 mg/kg over 15 mg/kg of intravenous dipyrone based on better movement-induced pain control, lower morphine consumption and fewer opioid-related side effects.

La omisión de la relajación neuromuscular en pacientes ambulatorios que requieren intubación orotraqueal incrementa temporalmente la incidencia de síntomas laríngeos postoperatorios: estudio cuasi-experimental / The avoidance of neuromuscular paralysis in outpatients requiring endotracheal intubation temporarily increases the incidence of postoperative laryngeal symptoms: quasi-experimental study

Introducción. Las técnicas de intubación endotraqueal sin relajación neuromuscular han crecido en popularidad, pero su impacto en unidades quirúrgicas donde existe personal en entrenamiento es desconocido. Objetivo. Evaluar el impacto de omitir la relajación neuromuscular, en términos de incidencia de disfonía y odinofagia, en pacientes sometidos a procedimientos ambulatorios cortos que requieren intubación endotraqueal en una unidad quirúrgica académica universitaria. Método. Estudio cuasi-experimental, no aleatorizado, doble ciego, en pacientes adultos programados para cirugía ambulatoria que requerían intubación endotraqueal. El grupo de no relajación recibió lidocaína (1,5 mg kg-1), propofol (1,5-2 mg kg-1) y remifentanil 4 mcg kg-1, y el grupo de relajación recibió la misma técnica, y se adicionó rocuronio a dosis de 0,3-0,6 mg kg-1. Los desenlaces primarios se evaluaron a los días 1, 3 y 14 postoperatorios. Resultados. Se incluyeron 287 pacientes. El 51,7 % recibió relajante neuromuscular. La incidencia de disfonía fue estadísticamente mayor a las 24 horas en el grupo de no relajante (26 % frente a 15 %; valor p: 0,016); así, no fue significativa a las 72 horas de seguimiento (0,6 % frente a 0 %; valor de p 0,37). No se encontraron diferencias en la incidencia de odinofagia entre los grupos. Los síntomas habían desaparecido en toda la población estudiada a la semana de seguimiento. Conclusiones. Omitir la relajación neuromuscular se asocia con un incremento transitorio de disfonía a las 24 horas del posoperatorio, pero no de odinofagia. No existen diferencias en la incidencia de síntomas laríngeos en 72 horas. La adición de relajante neuromuscular para disminuir la incidencia de disfonía temprana puede estar justificada.

Introduction. Endotracheal intubation without neuromuscular relaxation has become more common, but its impact on surgical units of teaching hospitals is unknown. Objective. To assess the impact of avoiding neuromuscularrelaxation in terms of incidence ofhoarseness and sore throat in ambulatory surgery patients requiring endotracheal intubation in surgical unit of a teaching hospital. Method. A quasi-experimental, non-randomized, double-blind study in adult patients undergoing outpatient surgery requiring endotracheal intubation. The non muscle relaxant group received lidocaine (1.5 mg kg-1), propofol (1.5 - 2 mg kg-1) and remifentanil 4 mcg * kg-1 and the muscle relaxation group received the same technique and rocuronium 0.3 to 0.6 mg * kg-1. The primary outcomes were assessed at days 1, 3 and 14.Results. We enrolled 287 patients, where 51.7 % received rocuronium. The incidence of hoarseness was significantly higher at 24 hours in the nonrelaxant group (26 % vs. 15 %, p value: 0.016) being not significant after 72 hours of follow up (0.6 % vs. 0 %; p: 0.37). We found no differences inthe incidence of sore throat between the groups. All the study patients were asymptomatic at one week. Conclusions. Avoidance of neuromuscular relaxationis associated with a transient (First 24hours) increase in hoarseness after ambulatory surgery, but no difference in sore throat. We found no differences in the incidence of laryngeal symptoms after 72 hours. The addition of musclerelaxant to reduce the incidence of hoarseness can be justified.

Effectiveness of combined haloperidol and dexamethasone versus dexamethasone only for postoperative nausea and vomiting in high-risk day surgery patients: a randomized blinded trial.

BACKGROUND AND OBJECTIVE: To examine whether prophylactic use of haloperidol in addition to dexamethasone decreased the incidence of postoperative nausea and vomiting in high-risk patients undergoing ambulatory surgery. METHODS: One hundred and sixty nonsmoking women aged between 18 and 50 years receiving a standardized anaesthesia, which included dexamethasone 8 mg at the beginning of cosmetic or ENT surgery, were enrolled. They were randomized to receive either 1.5 mg of haloperidol (dexamethasone-haloperidol group) or placebo (dexamethasone-placebo group) 30 min before the end of surgery. The incidence of postoperative nausea and vomiting was assessed by a blinded investigator at 30 min, 2, 6, and 24 h in the postoperative period. Analgesic requirements, eye opening time, and sedation were also assessed. RESULTS: We found no differences in nausea or vomiting at 30 min and 2 h postoperatively; we found no difference in the incidence of nausea between dexamethasone-haloperidol and dexamethasone-placebo groups at 6 h [relative risk (RR) 0.82, 95% confidence interval (CI) 0.56-1.25] and 24 h (RR 0.79, 95% CI 0.56-1.1), but the cumulative incidence of vomiting in the dexamethasone-haloperidol group was significantly lower at 6 h (RR 0.57, 95% CI 0.39-1.05) and 24 h (RR 0.54, 95% CI 0.31-0.86). We found no differences in eye opening time and Ramsay score higher than 2 at 30 min and 2 h after surgery. CONCLUSION: To combine 1.5 mg of haloperidol and 8 mg of dexamethasone reduces the cumulative incidence of postoperative vomiting at 6 and 24 h postoperatively in day patients at high risk of postoperative nausea and vomiting.

Añadir haloperidol a la morfina para la analgesia controlada por el paciente (PCA) reduce náusea y vómito tras una cirugía de corta estancia en el hospital: un ensayo clínico aleatorio, controlado / Adding haloperidol to morphine for patient-controlled analgesia (PCA) reduces nausea and vomiting after short stay surgery: randomized, controlled

Background: Morphine Patient-Controlled Analgesia (PCA) increases the frequency of postoperative nausea and vomiting (PONV) and the effectiveness adding haloperidol is unknown. Methods: 145 women scheduled to undergo short-stay surgery under general anaesthesia were randomly assigned in two groups: One group received 2 mg i.v. of haloperidol 30 minutes before the end of surgery plus 2 mg mixed with 50 mg of morphine for administration via PCA (Group H); the other group received the same analgesic scheme for pain management using two comparable i.v. boluses of saline (Group P). Furthermore, both groups received dexamethasone 4 mg during anaesthesia induction. Ondansetron (4 mg i.v.) was used for antiemetic rescue. significa Participants and outcomes assessors were blinded to group assignment. The primary endpoints were incidence of nausea, vomiting and antiemetic requirements during the first 24 hours after surgery. Secondary endpoints included sedation and morphine requirement. Results: Cumulative data at 24 hours showed that the group H had less nausea (71.2% vs. 20.6%; RR 0.29 [95% CI: 0.17-0.46]) and vomiting (47% vs. 11.8%; RR 0.25; [95% CI: 0.12-0.49]), and required less ondansetron (66.7% vs. 17.7%), but had an increased incidence of sedation (NNH: 3.5; 95% CI, 2.3-6.7). The NNT for Total response (no nausea, no vomiting/retching) was 2.5 (0-2 hours) and 2 (2-24 hours). Conclusion: A bolus of haloperidol 2 mg prior to the end of surgery followed by 2 mg mixed with 50 mg of Morphine for PCA administration can significantly reduce the frequency of PONV but at a cost of increased sedation.

Ketamina y analgesia preventiva en artroplastia primaria de cadera: Un estudio aleatorizado doble ciego / Ketamine and Pre-emptive analgesia in primary Hip Arthroplasty

Ketamina y Analgesia Preventiva, en Artroplastia Primaria de Cadera. Un estudio aleatorizado doble ciego. Evaluar la efectividad de la ketamina como estrategia de analgesia preventiva en artroplastia primaria de cadera, comparada con placebo. Estudio experimental, doble ciego, controlado. Se tomaron cincuenta pacientes sometidos a artroplastia primaria de cadera, bajo anestesia general y manejo del dolor postoperatorio con Morfina en analgesia controlada por el paciente (ACP). Previo a la inducción anestésica se aleatorizan en dos grupos: Grupo K: Ketamina 0,2 mg/Kg IV y Grupo P (Placebo): solución salina. Se administran previo a la incisión quirúrgica. Se toman en el postoperatorio las siguientes mediciones a las 24 horas: Intensidad del dolor, requerimientos analgésicos, frecuencia de nausea y vómito, satisfacción en el manejo. No se encontraron diferencias estadísticamente significativas en los dos grupos respecto a la intensidad del dolor, sin embargo para lograr el alivio del mismo se requirieron mayores dosis de morfina en el Grupo P, lo cual condujo a una frecuencia mayor de nausea y vómito en este último. La ketamina debe ser considerada como una alternativa útil de analgesia preventiva para disminuir el consumo de opioides en el postoperatorio y así mismo disminuir la frecuencia de efectos adversos que de estos últimos se derivan