High-intensity laser for the treatment of pain: systematic review / Laser de alta intensidade para tratamento da dor: revisão sistemática

ABSTRACT BACKGROUND AND OBJECTIVES: Pain is one of the most prevalent causes of disability in the world, and the adverse effects promoted by analgesics can limit therapeutic success. In this context, laser appears as a complementary therapy that can enhance analgesia without increasing the incidence of undesirable adverse events. The aim of this study was to carry out a systematic review on the effectiveness and efficiency of high intensity laser (HIL) in the treatment of pain. CONTENTS: A systematic search was carried out in Medline, LILACS, Pubmed and PEDro, from July 2020 to August 2022. The keywords pain, chronic pain, high intensity laser and treatment were considered. The quality of selected studies was assessed using the PEDro scale. Included systematic reviews were assessed for methodological quality using the AMSTAR tool. The main measure studied was pain intensity. 227 studies were found and, based on the inclusion and exclusion criteria, 32 articles were read in full, whit one being excluded for not assessing pain. Musculoskeletal disorders corresponded to 70,96% of the assessed diseases and the visual analogue scale (VAS) was the only pain measurement tool used in 100% of the studies. Approximately 57% of the studies were of high methodological quality (PEDro=7). In 53,84% of the trials, HIL was used as a single intervention, and in 46,16% it was associated whit exercises. In 96.15% of clinical trials and 100% of systematic reviews there were positive effects of HIL on pain. CONCLUSION: HIL is an effective modality for analgesia by promoting significant pain relief, rapid recovery and improvement in patient's quality of life, in a safe way. The diversity in irradiation parameters (dose, duration, interval and number of sessions) used, indicates the need for further randomized studies to establish its long-term efficiency.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é uma das causas mais prevalentes de incapacidade no mundo, e os efeitos adversos promovidos pelos analgésicos podem limitar o sucesso terapêutico. Nesse contexto, surge o laser como terapia complementar que pode potencializar a analgesia, sem aumentar incidência de eventos adversos indesejáveis. O objetivo deste estudo foi realizar uma revisão sistemática sobre a eficácia e a eficiência do laser de alta intensidade (LAI) no tratamento da dor. CONTEÚDO: Foi realizada uma busca sistemática nas plataformas Medline, LILACS, Pubmed e PEDro, de julho de 2020 a agosto de 2022. As palavras chaves dor, dor crônica, laser de alta intensidade e tratamento foram consideradas. A qualidade dos estudos clínicos selecionados foi avaliada utilizando a escala PEDro. As revisões sistemáticas incluídas foram avaliadas quanto à qualidade metodológica através da ferramenta AMSTAR. A principal medida estudada foi a intensidade de dor. Foram encontrados 227 estudos e com base nos critérios de inclusão e exclusão, 32 artigos foram lidos na íntegra, tendo sido excluído um por não avaliar a dor. As desordens musculoesqueléticas corresponderam a 70,96% das doenças avaliadas e a escala analógica visual (EAV) foi a única ferramenta de mensuração da dor utilizada em 100% dos estudos. Aproximadamente 57% dos estudos tinham alta qualidade metodológica (PEDro=7). Em 53,84% dos ensaios o LAI foi utilizado como intervenção única, e em 46,16% foi associado a exercícios. Em 96,15% dos ensaios clínicos e 100% das revisões sistemáticas, o LAI promoveu alívio da dor. CONCLUSÃO: O LAI é uma modalidade eficaz para analgesia ao promover significativo alívio da dor, rápida recuperação e melhora na qualidade de vida dos pacientes de forma segura. A diversidade nos parâmetros de irradiação (dose, duração, intervalo e número de sessões) empregados, indica a necessidade de mais estudos randomizados para estabelecer sua eficiência em longo prazo.

Comparative Study of Clinical and Ultrasound Parameters for Defining a Difficult Airway in Patients with Obesity.

INTRODUCTION: Patients with obesity have anatomical changes due to increased adipose tissue that negatively affect airway accessibility, making it difficult to establish an advanced airway through orotracheal intubation. This article aims to evaluate the correlation of clinical and sonographic parameters as predictors of difficult airway management (DAM) in patients with obesity and to establish the predictive value of the skin-epiglottis distance as an indicator of a probable DAM. METHODS: This is an observational, prospective study of 100 patients with obesity who underwent bariatric surgery over a 12-month period. The patients were categorized into the easy airway and the difficult airway groups, according to the Cormack-Lehane classification in the laryngoscopy evaluation, and the clinical and sonographic variables collected were statistically evaluated to obtain the relation with the presence of DAM, according to the Cormack-Lehane classification. RESULTS: The mouth opening (p = 0.010) and the skin-epiglottis distance (p = 0.019) were statistically significant when comparing the easy airway and the difficult airway groups of the Cormack-Lehane classification. The predictive value of the skin-epiglottis distance for difficult airway assessment was 29.3 mm. The neck circumference (p = 0.225), the Mallampati index (p = 0.260), and the other clinical variables showed no statistical relevance when compared in isolation with the Cormack-Lehane groups. CONCLUSION: The ultrasound method as a predictor of difficult intubation is promising in anesthetic practice when used according to standardized measurements evaluation and cutoff values.

Ultrasound-guided popliteal sciatic nerve block in a pediatric patient with complex regional pain syndrome: a case report.

In the pediatric population, complex regional pain syndrome (CRPS) is a challenging condition that leads to chronic psychosocial dysfunction. This case is of a 12-year-old male patient, 50 kg, who, after twisting his right ankle, started to present intense pain. Without adequate diagnosis and treatment, his family sought a pain specialist. During the evaluation, a change in sensitivity and temperature was observed, besides hyperalgesia, allodynia, redness, edema, and motor dysfunction, being diagnosed with CRPS. Ultrasound-guided sciatic blocks were performed on the affected limb, increasing the interval between crises, reducing pain intensity, and promoting a return to daily activities.

Combined spinal-epidural anesthesia for abdominoplasty and liposuction in Limb-Girdle Muscular Dystrophy: case report.

We report the anesthetic management with combined spinal-epidural in a patient with limb-girdle muscular dystrophy type 2A, submitted to abdominoplasty and liposuction. The patient had onset of symptoms at 8 years old, diagnosed by muscular biopsy, presenting muscle weakness in the scapular and pelvic girdles, with reduced mobility. We performed monitorization with noninvasive blood pressure, oximeter, thermometer, and electrocardiogram. In the postoperative period, she showed no clinical signs of rhabdomyolysis, myotonia, or adverse effects, maintaining hemodynamic stability. The anesthesia technique allowed spontaneous ventilation, monitoring of clinical parameters close to physiological conditions and used smaller doses of medication, reducing related risks.

Anesthesia for surgical repair of the pentalogy of Cantrell: case report / Anestesia em cirurgia para correção de pentalogia de Cantrell: relato de caso

Abstract Pentalogy of Cantrell is a congenital anomaly associated with defects in the abdominal wall, sternum, diaphragm, and diaphragmatic pericardium formation, in addition to the development of cardiac abnormalities. It is a rare disease with an estimated incidence of one case for every 65,000 births, being more common in males (60% of cases). It has a reserved prognosis with mortality around 63%, and a maximum of 9 months survival after surgery. There are few case reports addressing the pentalogy of Cantrell, which is justified by the rarity of this pathology. In this report our objective was to describe a surgical case of a female patient and make some anesthetic considerations about this rare congenital malformation.

Resumo A pentalogia de Cantrell é uma anomalia congênita associada a defeitos na formação da parede abdominal, do esterno, diafragma e pericárdio diafragmático, além do desenvolvimento de anomalias cardíacas. É uma doença rara, com incidência estimada em um caso para cada 65.000 nascimentos, mais comum no sexo masculino (60% dos casos). Apresenta prognóstico reservado com mortalidade em torno de 63% e sobrevida após procedimento cirúrgico de no máximo nove meses. São escassos os relatos de casos referentes à pentalogia de Cantrell, o que se justifica pela raridade dessa patologia. Com este relato, os autores objetivam descrever um caso cirúrgico, em paciente do sexo feminino, e tecer algumas considerações anestésicas sobre essa malformação congênita rara.

[Anesthesia for surgical repair of the pentalogy of Cantrell: case report]. / Anestesia em cirurgia para correção de pentalogia de Cantrell: relato de caso.

Pentalogy of Cantrell is a congenital anomaly associated with defects in the abdominal wall, sternum, diaphragm, and diaphragmatic pericardium formation, in addition to the development of cardiac abnormalities. It is a rare disease with an estimated incidence of one case for every 65,000 births, being more common in males (60% of cases). It has a reserved prognosis with mortality around 63%, and a maximum of 9 months survival after surgery. There are few case reports addressing the pentalogy of Cantrell, which is justified by the rarity of this pathology. In this report our objective was to describe a surgical case of a female patient and make some anesthetic considerations about this rare congenital malformation.

Intubação de via aérea difícil em paciente com síndrome de Treacher Collins / Difficult airway intubation in a patient with Treacher Collins syndrome - case report

A síndrome de Treacher Collins é uma patologia rara, com gene causador mapeado no braço longo do cromossomo cinco (5q31. 3-q33.3). Conhecida como disostose craniofacial, apresenta-se com hipoplasia malar, hipoplasia mandibular e malformações do pavilhão auricular. Tal condição representa previsão de dificuldade para o ato anestésico de intubação, necessitando de avaliação pré-operatória minuciosa e cuidado intensivo no perioperatório. A anestesia geral costuma ser realizada por indução de anestésicos inalatórios, uma vez que crianças submetidas a procedimentos cirúrgicos são não cooperativas, além de haver dificuldade de se obter acesso venoso. Assim, objetiva-se relatar caso de via aérea de intubação difícil em paciente com síndrome de Treacher Collins, correlacionando às manifestações clínicas, ao diagnóstico e ao tratamento cirúrgico, e revisando a literatura sobre o tema. Relatamos um caso cuja singularidade reside no manejo anestésico diferente dos executados em outros centros médicos, ao abordar pacientes com previsão de via aérea difícil. Ao invés de se utilizar máscara laríngea ou intubação com laringoscópio óptico, procedeu-se a: indução inalatória, sedação sem abolir respiração espontânea, visualização das estruturas para introdução do tubo endotraqueal (Cormack 3), acesso venoso, intubação orotraqueal e, posteriormente, indução anestésica e bloqueio neuromuscular. Julgamos importante divulgar tal relato para expor alternativas na indisponibilidade de certos dispositivos, como o fibroscópio. A técnica de intubação sem máscara laríngea ou fibroscópio em pacientes com síndrome craniofacial pode ocorrer sem intercorrências com a estratégia de não abolir a respiração do paciente, porém com leve sedação, devido à não cooperação e à dificuldade de se obter acesso venoso em crianças. (AU)

Treacher Collins syndrome is a rare disease with the culprit gene mapped on the distal long arm of chromosome five (5q31. 3-q33.3). It is known as craniofacial dysostosis, and presents with malar hypoplasia, mandibular hypoplasia, and pinnae malformations. Such condition represents expected difficult airway intubation during anesthesia, requiring detailed preoperative evaluation, and intensive perioperative care. General anesthesia is usually performed through inhaling anesthetics because children undergoing surgical procedures are not cooperative, and their venous access is difficult. Thus, the aim of the study is to report a case of difficult airway intubation in a patient diagnosed with Treacher Collins syndrome, correlating clinical manifestations, diagnosis e surgical treatment, and reviewing the literature on the subject. We report a case that is unique because the anesthetic management is different from what has been done in other medical centers, since it manages patients with expected difficult airway. Instead of using a laryngeal mask airway (LMA) device or a flexible optical intubation (FOI), an inhaling induction was performed, with preserved spontaneous breathing sedation, and visualization of the structures to receive the endotracheal tube (Cormarck 3), venous access, orotracheal intubation and then, anesthetic induction and neuromuscular block. We consider it important to share this report to give alternatives when some devices, such as the fiberscope, are not available. The intubation technique without laryngeal mask airway device or fiberscope in patients with craniofacial syndrome may take place with no complications, when the patient's spontaneous breathing is not aborted, but with light sedation, because of children's noncooperation, and difficulty venous access. (AU)

Hemodynamic alterations during orthotopic liver experimental transplantation in pigs.

PURPOSE: To describe the hemodynamic alterations during orthotopic liver transplantation in pigs. METHODS: In the period from April 2004 to December 2005, forty-four female Landrace pigs, weighting between 32 and 38 Kg underwent orthotopic liver transplantation. The animals were divided into two groups, donor and recipient pairs, which received whole liver grafts. The surgical procedure was divided into four parts: harvested, back-table, hepatectomy of the recipient and implantation. We analyzed heart rate, blood gas, mean systemic arterial pressure (MAP-mmHg), central venous pressure, pH, Na-, K+, Cl-, Ca+ and urinary output. RESULTS: The mean anhepatic time was 69 min, cold ischemia was 252.2 min and back-table was 56.6 min. Blood pressure and heart rate dropped significantly during anhepatic phase and after revascularization. Blood gas and electrolytes alterations were observed during anhepatic and reperfusion phases. Although alterations were noted during these phases, the hemodynamic status was recovered and stabilized in the end of the surgery. CONCLUSIONS: Simplified technique of liver transplant was achieved and description of hemodynamic alterations was possible in pigs.

Hemodynamics alterations during orthotopic liver experimental transplantation in pigs

PURPOSE: To describe the hemodynamics alterations during orthotopic liver transplantation in pigs. METHODS: In the period from April 2004 to December 2005, forty-four female Landrace pigs, weighting between 32 and 38 Kg were undergone to orthotopic liver transplantation. The animals were divided into two groups, donor and recipient pairs, which received whole liver grafts. The surgical procedure was divided into four parts: harvested, back-table, hepatectomy of the recipient and implantation. We analyze heart rate, blood gas, mean systemic arterial pressure (MAP-mmHg), central venous pressure, pH, Na-, K+, Cl-, Ca+ and urinary output. RESULTS: The mean anhepatic time was 69 min, cold ischemia was 252.2 min and back-table was 56.6 min. Blood pressure and heart rate dropped significantly during anhepatic phase and after revascularization. Blood gas and electrolytes alterations were observed during anhepatic and reperfusion phases. Although alterations were noted during these phases, the hemodynamic status was recovered and stabilized in the end of the surgery. CONCLUSIONS: Simplified technique of liver transplant was achieved and description of hemodynamic alterations was possible in pigs.

OBJETIVO: Descrever as alterações hemodinâmicas que ocorrem durante o transplante hepático ortotópico experimental em suínos. MÉTODOS: No período de abril de 2004 a dezembro de 2005, quarenta porcos da raça Landrace, fêmeas, pesando entre 32 e 38Kg foram submetidos a transplante hepático ortotópico. Os animais foram divididos em dois grupos, doador e receptor, estes receberam enxerto total. O procedimento cirúrgico foi dividido em captação, cirurgia de banco, hepatectomia do receptor e implante do enxerto. Analisamos a freqüência cardíaca, gasometria, pressão arterial média (PAM-mmHg), pressão venosa central, pH, Na-, K+, Cl-, Ca+, e débito urinário. RESULTADOS: O tempo médio de fase anepática foi de 69 minutos, tempo de isquemia fria foi de 252,2 minutos e cirurgia de banco de 56,6 minutos. A pressão sanguínea caiu significativamente e a freqüência cardíaca elevou-se durante a fase anepática e de revascularização. As alterações na gasometria e eletrólitos foram observadas durante as fases anepática e de revascularização. Embora estas alterações tenham sido observadas durante aquelas fases, o padrão hemodinâmico foi recuperado e estabilizado no final da operação. CONCLUSÕES: Uma técnica simplificada de transplante hepático experimental teve seu objetivo alcançado e foi possível identificar corrigir as alterações hemodinâmicas encontradas em suínos.