Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial / Comparação entre morfina subaracnoidea e bloqueio do nervo femoral para analgesia após reconstrução ligamentar de joelho: estudo clínico randomizado

Abstract Background and objectives There are no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia. Method Randomized and controlled clinical trial of patients undergoing reconstruction of the Anterior Cruciate Ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The groups C, M, R0,375 and R0,25 was compared with only the previously described technique, subarachnoid morphine (100░µg), or Femoral Nerve Block (BNF) with 25░mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24░hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated. Results Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24░hours. There was a higher incidence of urinary retention in the M group (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 group (30%) than in the M and C groups (0%), with statistical significance (p░<░0.05). Conclusion There was no difference in the intensity of postoperative pain in patients submitted to ACL reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M group and motor block in the R0,375 group.

Resumo Justificativa e objetivos Não há consenso sobre qual é a técnica ideal para prover analgesia em reconstruções ligamentares de joelho. Objetivou‐se comparar a intensidade da dor pós‐operatória desses pacientes sob diferentes modalidades de analgesia. Método Ensaio clínico randomizado e controlado de pacientes submetidos à reconstrução do ligamento cruzado anterior com tendões flexores entre dezembro de 2013 e 2014. Todos os pacientes foram submetidos a raquianestesia e analgesia de resgate com tramadol. Compararam‐se os grupos C, M, R0,375 e R0,25; aos quais se ofertou apenas a técnica anteriormente descrita, morfina subaracnóidea (100 µg) ou bloqueio de nervo femoral com 25 mL de ropivacaína 0,375% e 0,25%, respectivamente. Avaliou‐se intensidade da dor em 6, 12 e 24 horas, idade, sexo, analgesia de resgate, reações adversas e satisfação. Resultados Entre os 83 pacientes elegíveis, observou‐se predomínio do sexo masculino (85,7%) entre 28 e 31 anos. O Grupo C solicitou mais opioide (27,3%) do que os demais grupos, sem significância quando comparados. Não houve diferenças significativas na intensidade da dor em 6, 12 e 24 horas. Houve maior incidência de retenção urinária no Grupo M (23,8%) do que no R0,375 (0%) e de bloqueio motor prolongado do quadríceps no Grupo R0,375 (30%) do que nos Grupos M e C (0%), com significância estatística (p< 0,05). Conclusão Não houve diferença na intensidade da dor pós‐operatória nos pacientes submetidos à reconstrução de ligamento cruzado anterior com tendões flexores sob as modalidades analgésicas avaliadas, apesar do predomínio de retenção urinária no Grupo M e bloqueio motor no Grupo R0,375.

Postoperative aesthetic and healing features of postectomy using three different surgical techniques: a randomized, prospective, and interdisciplinary analysis.

OBJECTIVE: to compare the postoperative esthetic and healing aspects of postectomy performed by different surgical techniques, based on the evaluation of different specialty expert professionals. METHODS: prospective and randomized clinical trial enrolling 149 preschool children with a medical indication for circumcision, divided into three groups: postectomy with the hemostatic device Plastibell® (PB group), conventional technique (CV group) and conventional with subcuticular stitches (SC group). Pictures were taken from patients at pre-defined angles on the 30th and 60th postoperative days. Photos were evaluated by three specialists (dermatologist, pediatrician and plastic surgeon), who assigned scores from 1 to 5 regarding the esthetic and healing features at each moment. Grades 4 or 5 from all specialists characterized "best result". Data were analysed to compare the used surgical techniques, the judgments from specialties and postoperative complications. RESULTS: most of the patients obtained the "best result" regarding healing (70%) and esthetics (56%). The final overall result showed the PB group as the best for healing (p=0.028) and the SC group as the best for esthetics (p=0.002). For the dermatologist, on the 60th postoperative day, the CV group presented the worst aesthetic result, whereas for the pediatrician and the plastic surgeon, the PB group presented the best healing result and the SC group had the best esthetic result. There was no difference between the groups regarding the presence of complications. CONCLUSION: the most common surgical techniques used to perform postectomy in children were differently assessed regarding healing and esthetic features by distinct medical professionals. The analysis of these two parameters among experts from related areas diverged among them and over time.

[Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial]. / Comparação entre morfina subaracnoidea e bloqueio do nervo femoral para analgesia após reconstrução ligamentar de joelho: estudo clínico randomizado.

BACKGROUND AND OBJECTIVES: There is no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia. METHOD: Randomized and controlled clinical trial of patients undergoing reconstruction of the anterior cruciate ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The Groups C, M, R0,375 and R0,25 were compared with only the previously described technique, subarachnoid morphine (100 µg) or femoral nerve block with 25 mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated. RESULTS: Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The Group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24hours. There was a higher incidence of urinary retention in the Group M (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 Group (30%) than in the M and C Groups (0%), with statistical significance (p < 0.05). CONCLUSION: There was no difference in the intensity of postoperative pain in patients submitted to anterior cruciate ligament reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M Group and motor block in the R0,375 Group.

Postoperative aesthetic and healing features of postectomy using three different surgical techniques: a randomized, prospective, and interdisciplinary analysis / Aspectos estético e cicatricial pós-operatórios da postectomia por três diferentes técnicas cirúrgicas: análise randomizada, prospectiva e interdisciplinar

ABSTRACT Objective: to compare the postoperative esthetic and healing aspects of postectomy performed by different surgical techniques, based on the evaluation of different specialty expert professionals. Methods: prospective and randomized clinical trial enrolling 149 preschool children with a medical indication for circumcision, divided into three groups: postectomy with the hemostatic device Plastibell® (PB group), conventional technique (CV group) and conventional with subcuticular stitches (SC group). Pictures were taken from patients at pre-defined angles on the 30th and 60th postoperative days. Photos were evaluated by three specialists (dermatologist, pediatrician and plastic surgeon), who assigned scores from 1 to 5 regarding the esthetic and healing features at each moment. Grades 4 or 5 from all specialists characterized "best result". Data were analysed to compare the used surgical techniques, the judgments from specialties and postoperative complications. Results: most of the patients obtained the "best result" regarding healing (70%) and esthetics (56%). The final overall result showed the PB group as the best for healing (p=0.028) and the SC group as the best for esthetics (p=0.002). For the dermatologist, on the 60th postoperative day, the CV group presented the worst aesthetic result, whereas for the pediatrician and the plastic surgeon, the PB group presented the best healing result and the SC group had the best esthetic result. There was no difference between the groups regarding the presence of complications. Conclusion: the most common surgical techniques used to perform postectomy in children were differently assessed regarding healing and esthetic features by distinct medical professionals. The analysis of these two parameters among experts from related areas diverged among them and over time.

RESUMO Objetivo: analisar os aspectos estético e cicatricial pós-operatórios (PO) de pacientes submetidos a postectomia por diferentes técnicas cirúrgicas a partir da avaliação de profissionais experientes de áreas afins. Método: ensaio clínico prospectivo e randomizado, incluindo 149 meninos em idade pré-escolar com indicação médica de postectomia, divididos em três grupos: postectomia com dispositivo hemostático Plastibell® (grupo PB), técnica convencional (grupo CV) e convencional com pontos subcuticulares (grupo SC). Os pacientes foram fotografados em ângulos predefinidos no 30º e 60º dias de PO e as fotos avaliadas por três especialistas (dermatologista, pediatra e cirurgião plástico) que atribuíram notas entre 1 e 5, quanto aos aspectos estético e cicatricial em cada momento. Notas 4 ou 5 de todos os especialistas caracterizaram o "melhor resultado". Os dados foram submetidos à análise estatística para comparar as técnicas cirúrgicas, as avaliações dos especialistas e as complicações pós-operatórias. Resultados: a maioria dos pacientes obteve "melhor resultado" cicatricial (70%) e estético (56%). O resultado geral final apontou o grupo PB como superior quanto à cicatrização (p=0,028) e o grupo SC quanto ao aspecto estético (p=0,002). Para o dermatologista, na segunda avaliação, o grupo CV apresentou o pior resultado estético, enquanto para o pediatra e o cirurgião plástico, o grupo PB apresentou o melhor resultado cicatricial e o grupo SC o melhor resultado estético. Não houve diferença entre os grupos quanto à presença de complicações. Conclusão: as técnicas cirúrgicas mais empregadas para realizar postectomia em crianças foram avaliadas quanto aos resultados cicatricial e estético de distintas maneiras. A análise desses dois parâmetros entre especialistas de áreas afins divergiu entre eles e ao longo do tempo.

Uso de Baixa Dose de Cetamina (+) no Pós-Operatório de Artrodese Lombar / Postoperative Low Dose Intravenous Ketamine (+) after Lumbar Arthrodesis

Introdução: A utilização de cetamina em baixas doses apresenta perspectivas promissoras na analgesia pós-operatória. Objetivo: Avaliar o efeito analgésico, poupador de opioide e a ocorrência de efeitos colaterais do uso de baixas doses de cetamina S (+) no pós-operatório de artrodese coluna lombar. Materiais e Métodos: Houve dois grupos de estudo - grupo 1 recebeu analgesia regular no pós-operatório e o grupo 2 recebeu a mesma medicação acrescida da infusão de cetamina S (+), 0,5 mg/kg/min, nas primeiras 48h. Resultados: 51 pacientes completaram o estudo (26 no grupo 1, 25 grupo no 2). Não houve diferença significativa em relação a quantidade média de morfina utilizada e ocorrência de efeitos colaterais. O valor médio de EVA foi de 4.1 no grupo 1 e 3.2 no grupo 2. Conclusão: O uso de baixas doses de cetamina S(+) no pós-operatório de artrodese lombar promove melhora da analgesia sem aumentar a incidência de efeitos adversos

Introduction: Low doses of ketamine or isomers are promising possibilities for anesthesia and postoperative analgesia. Objectives: The aim of this study is to demonstrate the analgesic efficacy, opioid-sparing effect and occurrence of side effect of low dose ketamine (+) in patients undergoing lumbar arthrodesis. MaterialandMethod: There was two groups, group 1 received regular analgesia, group 2 received regular analgesia plus IV ketamine S(+) infusion (0,5mg/kg/min) in the first 48 hours postoperatively. Results: Fifty-one patients completed the study (25 ketamine group, 26 control group). No difference in side effects was noted between the groups. Patients in ketamine group received at median 25.9 mg IV morphine versus 26.8 in control group (P > 0.05). Pain report in VAS was 3.2 in ketamine group and 4.1 in control group (P < 00.5). Conclusion: The addition of IV low dose ketamine S(+) infusion regimen improve postoperative analgesia without increase of side effects

Auditory Nerve Recovery Function in Cochlear Implant Surgery with Local Anesthesia and Sedation versus General Anesthesia.

OBJECTIVE: To analyze auditory nerve recovery function (REC), comparing the results after local anesthesia and sedation with those after general anesthesia. METHODS: This was a prospective, cross-sectional and descriptive study in a tertiary referral center hospital. We included all patients (37 ears) who underwent surgery for cochlear implant under either general anesthesia or local anesthesia and sedation during 3 years. REC was measured according to the function of 3 components, 'T0', 'A' and 'tau', and was taken for 3 cochlear electrodes (apical, medial and basal). RESULTS: There were no significant differences in 'tau' and in the current level used, but there were significant differences in the parameters 'T0' apical and 'A' basal. CONCLUSIONS: There were no significant differences in REC between the 2 types of anesthesia, except for the parameters 'T0' apical and 'A' basal.

IMPLEMENTATION AND VALIDATION OF STATISTICAL TESTS IN RESEARCH'S SOFTWARE HELPING DATA COLLECTION AND PROTOCOLS ANALYSIS IN SURGERY.

BACKGROUND: The use of information technology is often applied in healthcare. With regard to scientific research, the SINPE(c) - Integrated Electronic Protocols was created as a tool to support researchers, offering clinical data standardization. By the time, SINPE(c) lacked statistical tests obtained by automatic analysis. AIM: Add to SINPE(c) features for automatic realization of the main statistical methods used in medicine . METHODS: The study was divided into four topics: check the interest of users towards the implementation of the tests; search the frequency of their use in health care; carry out the implementation; and validate the results with researchers and their protocols. It was applied in a group of users of this software in their thesis in the strict sensu master and doctorate degrees in one postgraduate program in surgery. To assess the reliability of the statistics was compared the data obtained both automatically by SINPE(c) as manually held by a professional in statistics with experience with this type of study. RESULTS: There was concern for the use of automatic statistical tests, with good acceptance. The chi-square, Mann-Whitney, Fisher and t-Student were considered as tests frequently used by participants in medical studies. These methods have been implemented and thereafter approved as expected. CONCLUSION: The incorporation of the automatic SINPE

Comparison of turbinoplasty surgery efficacy in patients with and without allergic rhinitis / Comparação da eficácia da turbinoplastia em pacientes com e sem rinite alérgica

ABSTRACT INTRODUCTION: Turbinoplasty is a procedure that aims to reduce the size of the inferior turbinate through exuberant bone removal with high mucosal preservation. The procedure is recommended for patients with or without allergic rhinitis and those showing irreversible hypertrophy of inferior turbinates. OBJECTIVE: To evaluate the efficacy of inferior turbinoplasty for obstructive and non-obstructive symptoms in patients with or without allergic rhinitis. METHODS: Prospective study with 57 patients who underwent inferior turbinoplasty. They were evaluated for nasal obstruction, snoring, facial pressure, smell alterations, sneezing, nasal itching and runny nose symptoms, surgery time, and intraoperative bleeding. The last evaluation took place three months after surgery. RESULTS: Thirty-nine patients with allergic rhinitis and 18 without were assessed. Ninety days after surgery, 94.7% of patients showed degrees IV and V of breathing improvement; 89.5% showed moderate or complete improvement in snoring; all patients showed smell improvement (only one showed moderate improvement; all the others had full improvement); 95.5% experienced complete facial pressure improvement; and 89.7% showed moderate to complete improvement in nasal itching and runny nose symptoms, as well as in sneezing. CONCLUSION: The efficacy of inferior turbinoplasty was confirmed not only for obstructive symptoms, but also for non-obstructive symptoms in patients with and without allergic rhinitis.

RESUMO INTRODUÇÃO: A turbinoplastia é procedimento que visa a redução da concha inferior, à custa da remoção óssea exuberante e maior preservação da mucosa. É indicada para pacientes com e sem rinite alérgica, com hipertrofia irreversível das conchas inferiores. OBJETIVO: Avaliar a eficácia da cirurgia de turbinoplastia inferior nos sintomas obstrutivos e não obstrutivos em pacientes com e sem rinite alérgica. MÉTODO: Estudo prospectivo com 57 pacientes submetidos a turbinoplastia inferior. Foram avaliados quanto à obstrução nasal, roncos, pressão facial, alterações no olfato, espirros, prurido nasal e coriza, tempo de cirurgia e sangramento intraoperatório. A última avaliação foi com 3 meses de operação. RESULTADOS: 39 pacientes com rinite alérgica e 18 sem. Com 90 dias de operação, 94,7% dos pacientes apresentaram graus IV e V de melhora na respiração; 89,5% apresentaram melhora moderada ou total dos roncos; todos os pacientes tiveram melhora no olfato (apenas 1 moderada, os demais melhora total); 95,5% obtiveram melhora total da pressão facial e 89,7% obtiveram melhora moderada ou total em prurido nasal, espirros e coriza. CONCLUSÃO: Comprovou-se a eficácia da cirurgia de turbinoplastia inferior não só nos sintomas obstrutivos, mas também nos sintomas não obstrutivos tanto em pacientes com ou sem rinite alérgica.

Implementation and validation of statistical tests in research's software helping data collection and protocols analysis in surgery / Implementação e validação de testes estatísticos em software de pesquisa para coleta e análise de dados em protocolos de cirurgia

Background : The use of information technology is often applied in healthcare. With regard to scientific research, the SINPE(c) - Integrated Electronic Protocols was created as a tool to support researchers, offering clinical data standardization. By the time, SINPE(c) lacked statistical tests obtained by automatic analysis. Aim : Add to SINPE(c) features for automatic realization of the main statistical methods used in medicine . Methods : The study was divided into four topics: check the interest of users towards the implementation of the tests; search the frequency of their use in health care; carry out the implementation; and validate the results with researchers and their protocols. It was applied in a group of users of this software in their thesis in the strict sensu master and doctorate degrees in one postgraduate program in surgery. To assess the reliability of the statistics was compared the data obtained both automatically by SINPE(c) as manually held by a professional in statistics with experience with this type of study. Results : There was concern for the use of automatic statistical tests, with good acceptance. The chi-square, Mann-Whitney, Fisher and t-Student were considered as tests frequently used by participants in medical studies. These methods have been implemented and thereafter approved as expected. Conclusion : The incorporation of the automatic SINPE(c) Statistical Analysis was shown to be reliable and equal to the manually done, validating its use as a research tool for medical research.

Racional : O uso de tecnologias da informação é frequentemente aplicado na área da saúde. No que diz respeito à pesquisa científica, o SINPE(c) Sistema Integrado de Protocolos Eletrônicos foi criado como ferramenta para apoiar o pesquisador facilitando a coleta padronizada e confiável. Até o momento o SINPE(c) desta não dispunha de recurso de testes estatísticos para análise automática. Objetivo : Adicionar ao SINPE(c) recursos para a realização automática dos principais métodos estatísticos utilizados na medicina. Métodos : O estudo foi dividido em quatro tópicos: verificar o interesse dos usuários para com a implementação dos testes; pesquisar a frequência de uso deles na área da saúde; realizar a implementação; e validar os resultados com os pesquisadores e seus respectivos protocolos. Foi utilizado em um grupo de usuários deste software em seus trabalhos de tese no sistema de pós-graduação estrito senso em cirurgia. Para aferir a confiabilidade dos resultados estatísticos foi utilizada comparação dos dados obtidos tanto na forma automática pelo SINPE(c) como na manual, realizada por estatístico de experiência nesse tipo de trabalho. Resultados : Houve interesse para com o uso de testes estatísticos e boa aceitação. Os testes considerados de uso frequente pelos participantes em trabalhos médicos foram qui-quadrado, Mann-Whitney, exato de Fisher e t-Student. Estes métodos foram implementados e, posteriormente, homologados conforme esperado. Conclusão : A incorporação de análise estatística automática no SINPE(c) mostrou-se confiável e de igual resultado que a estatística manual, validando seu uso como ferramenta para pesquisa na área médica.

Comparison of turbinoplasty surgery efficacy in patients with and without allergic rhinitis.

INTRODUCTION: Turbinoplasty is a procedure that aims to reduce the size of the inferior turbinate through exuberant bone removal with high mucosal preservation. The procedure is recommended for patients with or without allergic rhinitis and those showing irreversible hypertrophy of inferior turbinates. OBJECTIVE: To evaluate the efficacy of inferior turbinoplasty for obstructive and non-obstructive symptoms in patients with or without allergic rhinitis. METHODS: Prospective study with 57 patients who underwent inferior turbinoplasty. They were evaluated for nasal obstruction, snoring, facial pressure, smell alterations, sneezing, nasal itching and runny nose symptoms, surgery time, and intraoperative bleeding. The last evaluation took place three months after surgery. RESULTS: Thirty-nine patients with allergic rhinitis and 18 without were assessed. Ninety days after surgery, 94.7% of patients showed degrees IV and V of breathing improvement; 89.5% showed moderate or complete improvement in snoring; all patients showed smell improvement (only one showed moderate improvement; all the others had full improvement); 95.5% experienced complete facial pressure improvement; and 89.7% showed moderate to complete improvement in nasal itching and runny nose symptoms, as well as in sneezing. CONCLUSION: The efficacy of inferior turbinoplasty was confirmed not only for obstructive symptoms, but also for non-obstructive symptoms in patients with and without allergic rhinitis.

Objective assessment of surgical technique in rotation and nasal projection variation / Avaliação objetiva da técnica cirúrgica na variação da rotação e projeção nasal

ABSTRACT INTRODUCTION: In rhinoplasty, facial esthetic analysis is critical for proper surgical planning. Parameters such as rotation and nasal projection should be routinely evaluated. Few studies have objectively assessed changes in facial angles postoperatively. OBJECTIVE: To evaluate the effectiveness of medial intercrural sutures and of rotation of the nasal tip on the increase of rotation and nasal projection in Caucasian patients undergoing primary rhinoplasty. METHODS: A prospective study carried out between 2011 and 2013, with 27 patients treated with primary rhinoplasty with a basic technique by the same surgeon, with medial intercrural sutures and rotation of the nasal tip. Rotation and nasal projection were measured from photographs obtained preoperatively and after 12 months. RESULTS: All 27 patients completed the study. The mean age was 27.1 years. There was a mean increase of 8.4° in the rotation - a statistically significant value. There was no significant change in the projection. CONCLUSION: The medial intercrural and nasal tip rotation sutures are effective in increasing nasal rotation in Caucasian patients undergoing rhinoplasty.

RESUMO INTRODUÇÃO: Na rinoplastia, a análise estética facial é essencial para um planejamento cirúrgico adequado. Parâmetros como rotação e projeção nasal devem ser rotineiramente avaliados. Há poucos estudos que avaliem objetivamente as mudanças nos ângulos faciais no pós-operatório. OBJETIVO: Avaliar a eficácia das suturas intercrura mediais e de rotação da ponta nasal no aumento da rotação e projeção nasal em pacientes caucasianos submetidos à rinoplastia primária. MÉTODO: Estudo prospectivo realizado entre 2011 e 2013, com 27 pacientes submetidos à rinoplastia primária técnica básica, pelo mesmo cirurgião, com suturas intercrura mediais e de rotação da ponta nasal. Mediu-se a rotação e a projeção nasal a partir de fotografias no pré-operatório e 12 meses após. RESULTADOS: Todos os 27 pacientes completaram o estudo. A idade média foi de 27,1 anos. Houve aumento médio de 8,4° na rotação, com significância estatística. Não houve alteração significativa na projeção. CONCLUSÃO: As suturas intercrura mediais e de rotação da ponta nasal são eficazes no aumento da rotação nasal em pacientes caucasianos submetidos à rinoplastia.

Objective assessment of surgical technique in rotation and nasal projection variation.

INTRODUCTION: In rhinoplasty, facial esthetic analysis is critical for proper surgical planning. Parameters such as rotation and nasal projection should be routinely evaluated. Few studies have objectively assessed changes in facial angles postoperatively. OBJECTIVE: To evaluate the effectiveness of medial intercrural sutures and of rotation of the nasal tip on the increase of rotation and nasal projection in Caucasian patients undergoing primary rhinoplasty. METHODS: A prospective study carried out between 2011 and 2013, with 27 patients treated with primary rhinoplasty with a basic technique by the same surgeon, with medial intercrural sutures and rotation of the nasal tip. Rotation and nasal projection were measured from photographs obtained preoperatively and after 12 months. RESULTS: All 27 patients completed the study. The mean age was 27.1 years. There was a mean increase of 8.4° in the rotation - a statistically significant value. There was no significant change in the projection. CONCLUSION: The medial intercrural and nasal tip rotation sutures are effective in increasing nasal rotation in Caucasian patients undergoing rhinoplasty.

[Subarachnoid clonidine and trauma response in cardiac surgery with cardiopulmonary bypass]. / Clonidina subaracnóidea e resposta ao trauma em cirurgias cardíacas com circulação extracorpórea.

BACKGROUND AND OBJECTIVES: The intense trauma response triggered by cardiopulmonary bypass can lead to increased morbidity and mortality. The present study evaluated whether clonidine, a drug of the class of α-2 agonists, administered by spinal route, without association with local anesthetics or opioids, reduces this response in cardiac surgery with cardiopulmonary bypass. METHOD: A total of 27 patients between 18 and 75 years old, divided by non-blinded fashion into a control group (15) and a clonidine group (12), were studied. All patients underwent identical technique of general anesthesia. Then, only the clonidine group received 1µgkg(-1) clonidine by spinal route. Levels of blood glucose, lactate and cortisol were measured at three consecutive times: T1, at the time of installation of invasive arterial pressure; T2, 10min after the first dose for cardioplegia; and T3, at the time of skin suture; and troponin I values at T1 and T3. The variation of results between T2-T1, T3-T2, and T3-T1 was also evaluated. RESULTS: There was a statistically significant difference only with respect to the variation in blood glucose in the clonidine group: T3-T2, p=0.027 and T3-T1, p=0.047. CONCLUSIONS: Spinal clonidine at a dose of 1µgkg(-1) did not decrease blood measurements of troponin, cortisol, or lactate. Blood glucose suffered a more moderate variation during the procedure in the clonidine group. This fact, already reported in the literature, requires further investigation to be clarified.

Subarachnoid clonidine and trauma response in cardiac surgery with cardiopulmonary bypass / Clonidina subaracnóidea e resposta ao trauma em cirurgias cardíacas com circulação extracorpórea / Clonidina subaracnoidea y respuesta al trauma en cirugías cardíacas con circulación extracorpórea

Background and objectives: The intense trauma response triggered by cardiopulmonary bypass can lead to increased morbidity and mortality. The present study evaluated whether clonidine, a drug of the class of α-2 agonists, administered by spinal route, without association with local anesthetics or opioids, reduces this response in cardiac surgery with cardiopulmonary bypass. Method: A total of 27 patients between 18 and 75 years old, divided by non-blinded fashion into a control group (15) and a clonidine group (12), were studied. All patients underwent identical technique of general anesthesia. Then, only the clonidine group received 1 μg kg−1 clonidine by spinal route. Levels of blood glucose, lactate and cortisol were measured at three consecutive times: T1, at the time of installation of invasive arterial pressure; T2, 10 min after the first dose for cardioplegia; and T3, at the time of skin suture; and troponin I values at T1 and T3. The variation of results between T2-T1, T3-T2, and T3-T1 was also evaluated. Results: There was a statistically significant difference only with respect to the variation in blood glucose in the clonidine group: T3-T2, p = 0.027 and T3-T1, p = 0.047. Conclusions: Spinal clonidine at a dose of 1 μg kg−1 did not decrease blood measurements of troponin, cortisol, or lactate. Blood glucose suffered a more moderate variation during the procedure in the clonidine group. This fact, already reported in the literature, requires further investigation to be clarified. .

Justificativa e objetivos: A intensa resposta ao trauma desencadeada pela circulação extracorpórea pode conduzir ao aumento da morbimortalidade. 0 presente estudo avaliou se a clonidina, fàrmaco da classe dos α-2 agonistas, por via raquidiana, sem associação com anestésicos locais ou opioides, reduz essa resposta em cirurgias cardíacas com uso de circulação extracorpórea. Método: Estudaram-se 27 pacientes entre 18 e 75 anos, separados de modo não encoberto em grupo controle (15) e grupo clonidina (12). Todos foram submetidos a técnica idéntica de anestesia geral. A seguir, apenas o grupo clonidina recebeu 1 mg.kg−1 de clonidina por via raquidiana. Foram dosados os valores de glicemia, lactato e cortisol em trés tempos consecutivos: T1, no momento da instalação da pressão arterial invasiva (PAM); T2, dez minutos após a primeira dose de cardioplegia; e T3 na sutura da pele, bem como os valores de troponina I em T1 e T3. Avaliou-se também a variação dos resultados entre: T2-T1; T3-T2 e T3-T1. Resultados: Houve diferença estatisticamente significativa apenas quanto à variação da glicemia no grupo clonidina: T3-T2 valor de p=0,027 e T3-T1 valor de p = 0,047. Conclusões: A clonidina espinhal em dose de 1 μg.kg−1 não diminuiu as dosagens sanguineas de troponina, cortisol ou lactato. A glicemia sofreu urna menor variação durante o procedimento no grupo clonidina. Esse fato, já registrado na literatura, necessita de maiores investigações para ser esclarecido. .

Introducción y objetivos: La intensa respuesta al trauma desencadenada por la circulación extracorpórea puede conducir al aumento de la morbimortalidad. El presente estudio eva-luó si la clonidina, fármaco de la clase de los α-2 agonistas, por vía raquídea, sin asociación con anestésicos locales u opiáceos, reduce esa respuesta en cirugías cardíacas con el uso de circulación extracorpórea. Método: Se estudiaron 27 pacientes entre 18 y 75 años, separados de modo no enmascarado en un grupo control (15) y un grupo clonidina (12). Todos fueron sometidos a la técnica idéntica de anestesia general. A continuación, solamente el grupo clonidina recibió 1 mgkg−1 de clonidina por vía raquídea. Se dosificaron los valores de glucemia, lactato y cortisol en 3 tiempos consecu-tivos: T1, al momento de la instalación de la presión arterial invasiva (PAP); T2, 10 min después de la primera dosis de cardioplejia; y T3 en la sutura de la piel, como también los valores de troponinai en T1 y T3. Evaluamos también la variación de los resultados entre T2-T1, T3-T2 y T3-T1. Resultados: Hubo una diferencia estadísticamente significativa solamente en cuanto a la variación de la glucemia en el grupo clonidina: T3-T2 valor de p = 0,027 y T3-T1 valor de p = 0,047. Conclusiones: La clonidina espinal en dosis de 1 μgkg−1 no disminuyó las dosificaciones sanguíneas de troponina, cortisol o lactato. La glucemia experimentó una menor variación durante el procedimiento en el grupo clonidina. Ese hecho, ya registrado en la literatura, necesita más investigaciones para ser clarificado. .

Subthalamic nucleus lesion improves cell survival and functional recovery following dopaminergic cell transplantation in parkinsonian rats.

Subthalamic nucleus (STN) modulation is currently the gold standard in the treatment of Parkinson's disease (PD) cases refractory to medication. Cell transplantation is a tissue-restorative approach and is a promising strategy in the treatment of PD. One of the obstacles to overcome in cell therapy is the poor dopaminergic cell survival. Our experiment investigates the impact of a partial subthalamotomy prior to ventral mesencephalic (VM) embryonic cell transplantation on dopaminergic cell survival and functional outcome. Unilateral dopamine depletion was carried out in rats, via medial forebrain bundle (MFB) injection of 6-hydroxydopamine, and half of the animals went on to receive unilateral excitotoxic lesions of the STN/Zone Incerta (ZI) causing partial lesion of these structures on the same side as the MFB lesion. All MFB-lesioned animals, with or without the STN/ZI lesion, received striatal ipsilateral embryonic VM cell grafts. The data suggest that the STN/ZI lesion could boost the dopamine cell survival in the grafts by 2.6-fold compared with the control grafted-only group. Moreover, performance on the drug-induced rotation and the spontaneous behavior tests were ameliorated on the STN/ZI-lesioned group to a significantly greater extent than the grafted-only group. These data suggest that the STN/ZI partial lesion optimized the striatal environment, promoting an improvement in cell survival. Further studies are needed to see whether the synergy between STN modulation via deep brain stimulation and cell therapy might have clinical applications in the management of PD.

Cochlear implant surgery with local anesthesia and sedation: comparison with general anesthesia.

OBJECTIVES: The purpose of this study is to evaluate the possibility of performing cochlear implant surgery under local anesthesia and sedation and to evaluate the response of patients under sedation at the time of neural telemetry, comparing the differences with general anesthesia. PATIENTS: Twenty adult patients with bilateral sensorineural profound hearing loss submitted to cochlear implant surgery under general anesthesia and 20 patients under local anesthesia and intravenous sedation in the period from February 2011 to February 2012. The study was approved by the ethical committee of the institution. INTERVENTION: In both groups, we compared the costs of anesthesia, surgical time, time in recovery room, length of hospital stay, postoperative symptoms (pain, nausea, vomiting, and dizziness) and the degree of patient satisfaction. Besides, the reactions of the patients in the moment of the neural telemetry were also analyzed. MAIN OUTCOME MEASURES: The endpoint of this study is to establish the possibility of doing cochlear implant surgery with local anesthesia and sedation, discussing the differences and advantages over general anesthesia. RESULTS: By t-test variables, time in recovery room, time in hospital stay, and cost of inpatient anesthesia differ between groups, being always lower in the group of local anesthesia with sedation. The same result can be obtained using the Wilcoxon test. The symptoms of nausea, vomiting, and dizziness did not differ in the 2 groups. CONCLUSION: We conclude that the realization of the cochlear implant surgery under local anesthesia, and sedation is perfectly feasible with some advantages over general anesthesia. There were no problems during the neural telemetry performed by the time of the surgery in patients with local anesthesia with sedation.

Análise do potencial citotóxico agudo da bupivacaína e bupivacaína em excesso enantiomerico de 50 por cento (S75-R25) incorporadas a microesferas sobre o nervo ciático de ratos / Analysis of the acute cytotoxic potential of bupivacaine and 50 percent enantiomeric excess bupivacaine (S75-R25) incorporated into microspheres in rat sciatic nerves / Análisis del potencial citotóxico agudo de la bupivacaína y bupivacaína en exceso enantiomérico de 50 por ciento (S75-R25) incorporadas a microesferas sobre el nervio ciático de ratones

JUSTIFICATIVA E OBJETIVOS: A duração do efeito dos anestésicos locais (AL) pode ser ampliada pela sua incorporação aos sistemas de liberação prolongada como microesferas. No entanto, a possibilidade de que os sistemas de liberação prolongada de AL sejam neurotóxicos não tem recebido a devida atenção na literatura. Este estudo teve o objetivo de investigar os efeitos de microesferas de ácido poliláctico-co-glicólico puras, preenchidas com bupivacaína em excesso enantiomérico de 50 por cento ou com bupivacaína (BP), assim como os efeitos da bupivacaína em excesso enantiomérico de 50 por cento em nervo ciático de ratos Wistar. MÉTODO: Os ratos foram alocados em quatro grupos de acordo com o tempo de avaliação (dois, quatro, seis e oito dias) e denominados conforme a solução injetada sobre o nervo ciático: microsferas com bupivacaína em excesso enantiomérico de 50 por cento (MBE), microesferas com bupivacaína (MB); microesferas puras (MP) e bupivacaína em excesso enantiomérico de 50 por cento (BE). RESULTADOS: Nos cortes histológicos semifinos observou-se distribuição regular homogênea nas fibras de colágeno no endoneuro e nenhuma alteração degenerativa dos axônios ou das bainhas de mielina foi constatada. Nos cortes ultrafinos foram observados axônios mielinizados e fibras de Remak de aspecto normal com axoplasma apresentando distribuição homogênea de neurofilamentos e microtúbulos. A análise histomorfométrica dos axônios não revelou diferença significativa entre os diâmetros dos axônios dos grupos estudados.

BACKGROUND AND OBJECTIVES: The duration of Local Anesthetic (LA) effects can be expanded by its incorporation into systems of sustained release microspheres. However, the possibility that LA sustained release systems are neurotoxic has not received due attention in literature. The objective of this study was to investigate the effects of pure microspheres of poly(lactic-co-glycolic acid), filled with 50 percent enantiomeric excess bupivacaine or bupivacaine (BP), as well as the effects of 50 percent enantiomeric excess bupivacaine in the sciatic nerve of Wistar rats. METHODS: The rats were allocated into four groups according to the evaluation time (two, four, six, and eight days) and nominated according to the injected solution on the sciatic nerve: Microspheres with 50 percent Enantiomeric excess Bupivacaine (MEB), Microspheres with Bupivacaine (MB), Pure Microspheres (PM), and 50 percent Enantiomeric excess Bupivacaine (EB). RESULTS: In semi-fine histologic sections, no regular homogeneous distribution of collagen fibers in the endoneurium or degenerative changes of axons and myelin sheaths were observed. In ultrathin sections, we found myelinated axons and normal Remak fibers with axoplasm showing homogeneous distribution of neurofilaments and microtubules. Histomorphometric analysis of axons revealed no significant difference between the axon diameters of the studied groups.

JUSTIFICATIVA Y OBJETIVOS: La duración del efecto de los anestésicos locales (AL), puede ser ampliada por su incorporación a los sistemas de liberación prolongada como microesferas. Sin embargo, la posibilidad de que los sistemas de liberación prolongada de AL sean neurotóxicos, no ha recibido la debida atención en la literatura. Este estudio tuvo el objetivo de investigar los efectos de microesferas de ácido poliláctico-co-glicólico puras, rellenados con bupivacaína en exceso enantiomérico de 50 por ciento o con bupivacaína (BP), como también los efectos de la bupivacaína en exceso enantiomérico de 50 por ciento en nervio ciático de ratones Wistar. MÉTODO: Los ratones se dividieron en cuatro grupos de acuerdo con el tiempo de evaluación (dos, cuatro, seis y ocho días), y fueron denominados conforme a la solución inyectada sobre el nervio ciático: microesferas con bupivacaína en exceso enantiomérico de 50 por ciento (MBE), microesferas con bupivacaína (MB); microesferas puras (MP) y bupivacaína en exceso enantiomérico de 50 por ciento (BE). RESULTADOS: En los cortes semifinos se observó la distribución regular homogénea en las fibras de colágeno en el endoneuro y no se comprobó ninguna alteración degenerativa de los axones o de las vainas de mielina. En los cortes ultrafinos fueron observados axones mielinizados y fibras de Remak de aspecto normal con axoplasma presentando una distribución homogénea de neurofilamentos y microtúbulos. El análisis histomorfométrico de los axones no reveló diferencias significativas entre los diámetros de los axones de los grupos estudiados.

Analysis of the acute cytotoxic potential of bupivacaine and 50% enantiomeric excess bupivacaine (s75-r25) incorporated into microspheres in rat sciatic nerves.

BACKGROUND AND OBJECTIVES: The duration of Local Anesthetic (LA) effects can be expanded by its incorporation into systems of sustained release microspheres. However, the possibility that LA sustained release systems are neurotoxic has not received due attention in literature. The objective of this study was to investigate the effects of pure microspheres of poly(lactic-co-glycolic acid), filled with 50% enantiomeric excess bupivacaine or bupivacaine (BP), as well as the effects of 50% enantiomeric excess bupivacaine in the sciatic nerve of Wistar rats. METHODS: The rats were allocated into four groups according to the evaluation time (two, four, six, and eight days) and nominated according to the injected solution on the sciatic nerve: Microspheres with 50% Enantiomeric excess Bupivacaine (MEB), Microspheres with Bupivacaine (MB), Pure Microspheres (PM), and 50% Enantiomeric excess Bupivacaine (EB). RESULTS: In semi-fine histologic sections, no regular homogeneous distribution of collagen fibers in the endoneurium or degenerative changes of axons and myelin sheaths were observed. In ultrathin sections, we found myelinated axons and normal Remak fibers with axoplasm showing homogeneous distribution of neurofilaments and microtubules. Histomorphometric analysis of axons revealed no significant difference between the axon diameters of the studied groups.

Controle da dor por bloqueio peridural e incidência de disritmias cardíacas no pós-operatório de procedimentos cirúrgicos torácicos e abdominais altos: estudo comparativo / Control of pain trough epidural block and incidence of cardiac dysrhythmias in postoperative period of thoracic and major abdominal surgical procedures: a comparative study

JUSTIFICATIVA E OBJETIVOS: Operações no abdome superior e tórax provocam intensa dor. Entre as principais complicações da dor pós-operatória estão as complicações cardiocirculatórias. O objetivo deste trabalho foi testar a hipótese de que a analgesia pós-operatória com o emprego de anestésicos locais mais opioides espinhais pode reduzir a incidência de complicações cardiovasculares no pós-operatório de pacientes nessas condições, comparando-se a métodos clássicos de analgesia pós-operatória, opioides e AINES, administrados segundo demanda do paciente. MÉTODO: Oitenta pacientes adultos ASA I e II, sem alterações ECG, alocados em dois grupos de 40: Grupo A, sob anestesia geral com propofol, cisatracúrio e isoflurano, associado à anestesia peridural, com cateter e controle da analgesia pós-operatória com bupivacaína e morfina peridural; e Grupo B, sob anestesia geral com as mesmas drogas e doses que o Grupo A, mais analgesia pós-operatória realizada com AINES e morfina endovenosa no final da operação e em intervalos regulares. Em ambos foi aplicado Holter por 24 horas. A avaliação da dor foi realizada pela escala analógica visual. RESULTADOS: Na avaliação da dor observou-se no Grupo A evidente predomínio do escore 0 (p < 0,001) e também houve redução dos níveis de pressão arterial no pós-operatório de forma mais acentuada. As disritmias ventriculares e supraventriculares foram cinco vezes mais frequentes no Grupo B (p = 0,00001), em que também detectou-se tendência a maior frequência de extrassístoles ventriculares em idade > 50 anos (22,2 por cento versus 0,0 por cento. p = 0,26). Não se observou diferença significativa da frequência cardíaca entre os grupos (p > 0,05). CONCLUSÕES: A melhor qualidade da analgesia no pós-operatório, realizada nos pacientes do Grupo A, reduziu a incidência de complicações cardiovasculares.

BACKGROUND AND OBJECTIVES: Upper abdomen and thorax surgeries cause intense pain. Some of postoperative pain main complications are cardiocirculatory complications. The objective of this study was to test the hypothesis that postoperative analgesia with employment of local anesthetics plus spinal opioids may reduce the incidence of cardiovascular complications in postoperative period of patients in these conditions, comparing with classical methods of postoperative analgesia, opioids and NSAIDs, administered upon patient's demand. METHOD: Eighty adult patients, ASA I and II, without ECG alterations, were allocated into two groups of 40: Group A, patients under general anesthesia with propofol, cisatracurium and isoflurane, associated with epidural anesthesia with catheter and control of postoperative analgesia with bupivacaine and epidural morphine; and Group B, patients under general anesthesia with the same drugs and doses of A, plus postoperative analgesia carried out with NSAIDs and intravenous morphine at the end of surgery and in regular intervals. In both groups Holter was applied for 24 hours. Pain evaluation was carried out through visual analog scale. RESULTS: In pain evaluation, an evident predominance of 0 score (p < 0.001) was observed in Group A and there was also reduction of blood pressure levels in postoperative period in a more accentuated way. Ventricular and supraventricular dysrhythmias were five times more frequent in Group B (p = 0.00001), in which a tendency to a higher frequency of ventricular extrasystoles in age > 50 years (22.2 percent versus 0.0 percent. p = 0.26) was also detected. No significative difference of heart rate among groups (p > 0.05) was observed. CONCLUSIONS: The best quality of analgesia in postoperative period, carried out in Group A, reduced the incidence of cardiovascular complications.

JUSTIFICATIVA Y OBJETIVOS: Las operaciones en el abdomen superior y el tórax provocan un intenso dolor. Entre las principales complicaciones del dolor postoperatorio están las complicaciones cardiocirculatorias. El objetivo de este trabajo, fue comprobar la hipótesis de que la analgesia postoperatoria con el uso de los anestésicos locales y de los opioides espinales, puede reducir la aparición de complicaciones cardiovasculares en el postoperatorio de los pacientes que están en esas condiciones, comparando los métodos clásicos de analgesia postoperatoria, opioides y AINES, administrados según la demanda del paciente. MÉTODO: Ochenta pacientes adultos ASA I, II, sin alteraciones de ECG, fueron divididos en dos grupos de 40 cada uno: Grupo A, bajo anestesia general con propofol, cisatracurio e isoflurano, asociado a la anestesia epidural, con catéter y control de la analgesia postoperatoria con bupivacaína y morfina epidural; y Grupo B, bajo anestesia general con los mismos fármacos y dosis que el Grupo A, y con analgesia postoperatoria realizada con AINES y morfina ev al final de la operación, y en intervalos regulares. En ambos grupos se aplicó Holter por 24 horas. La evaluación del dolor fue realizada por la escala analógica visual. RESULTADOS: En la evaluación del dolor, se observó en el Grupo A un evidente predominio de la puntuación 0 (p < 0,001) y también hubo una reducción de los niveles de presión arterial en el postoperatorio de una forma más acentuada. Las arritmias ventriculares y supraventriculares fueron cinco veces más frecuentes en el Grupo B (p = 0,00001), donde también se detectó una tendencia para una mayor frecuencia de extrasístoles ventriculares en la edad > 50 años (22,2 por ciento versus 0,0 por ciento. P = 0,26). No se observó diferencia significativa de la frecuencia cardíaca entre los grupos (p > 0,05). CONCLUSIONES: La mejor calidad de la analgesia en el postoperatorio, realizada en el Grupo A...

Control of pain through epidural block and incidence of cardiac dysrhythmias in postoperative period of thoracic and major abdominal surgical procedures: a comparative study.

BACKGROUND AND OBJECTIVES: Upper abdomen and thorax surgeries cause intense pain. Some of postoperative pain main complications are cardiocirculatory complications. The objective of this study was to test the hypothesis that postoperative analgesia with employment of local anesthetics plus spinal opioids may reduce the incidence of cardiovascular complications in postoperative period of patients in these conditions, comparing with classical methods of postoperative analgesia, opioids and NSAIDs, administered upon patient's demand. METHOD: Eighty adult patients, ASA I and II, without ECG alterations, were allocated into two groups of 40: Group A, patients under general anesthesia with propofol, cisatracurium and isoflurane, associated with epidural anesthesia with catheter and control of postoperative analgesia with bupivacaine and epidural morphine; and Group B, patients under general anesthesia with the same drugs and doses of A, plus postoperative analgesia carried out with NSAIDs and intravenous morphine at the end of surgery and in regular intervals. In both groups Holter was applied for 24 hours. Pain evaluation was carried out through visual analog scale. RESULTS: In pain evaluation, an evident predominance of 0 score (p<0.001) was observed in Group A and there was also reduction of blood pressure levels in postoperative period in a more accentuated way. Ventricular and supraventricular dysrhythmias were five times more frequent in Group B (p=0.00001), in which a tendency to a higher frequency of ventricular extrasystoles in age>50 years (22.2% versus 0.0%. p=0.26) was also detected. No significative difference of heart rate among groups (p>0.05) was observed. CONCLUSIONS: The best quality of analgesia in postoperative period, carried out in Group A, reduced the incidence of cardiovascular complications.