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Anesth Analg ; 132(4): 1138-1145, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33617181


BACKGROUND: Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS: Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS: Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS: We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.

Analgesia Epidural , Nefrectomia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Ohio , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
Pain ; 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33021563


Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

J Bone Joint Surg Am ; 101(12): 1093-1101, 2019 Jun 19.
Artigo em Inglês | MEDLINE | ID: mdl-31220026


BACKGROUND: Often, differences in length of stay after total knee arthroplasty are solely attributed to patient factors. Therefore, our aim was to determine the influence of patient-related and procedure or structural-related risk factors as predictors of length of stay after total knee arthroplasty. METHODS: A prospective cohort of 4,509 patients (54.6% of whom had Medicare for insurance) underwent primary total knee arthroplasty across 4 facilities in a single health-care system (from January 1, 2016, to September 30, 2017). Risk factors were categorized as patient-related risk factors (demographic characteristics, smoking status, Veterans RAND 12 Item Health Survey Mental Component Summary score [VR-12 MCS], Charlson Comorbidity Index, surgical indication, Knee injury and Osteoarthritis Outcome Score [KOOS], deformity, range of motion, and discharge location probability assessed by a nomogram predicting location after arthroplasty) or as procedure or structural-related risk factors (hospital site, surgeon, day of the week when the surgical procedure was performed, implant type, and surgical procedure start time). Multivariable cumulative link (proportional odds logistic regression) models were built to identify significant predictors from candidate risk factors for 1-day, 2-day, and ≥3-day length of stay. Performance was compared between a model containing patient-related risk factors only and a model with both patient-related and procedure or structural-related risk factors, utilizing the Akaike information criterion (AIC) and internally validated concordance probabilities (C-index) for discriminating a 1-day length of stay compared with >1-day length of stay. RESULTS: Patient-related risk factors were significant predictors of length of stay (p < 0.05). A longer length of stay was predicted by older age, higher body mass index (BMI), higher Charlson Comorbidity Index, lower VR-12 MCS, and female sex. However, when the procedure or structural factors were added to the patients' risk factors, the AIC decreased by approximately 1,670 units. This indicates that procedure or structural-related risk factors provide clinically relevant improvement in explaining length of stay in addition to patient-related risk factors. CONCLUSIONS: Despite patient-related factors such as age, sex, and comorbidities providing substantial predictive value for length of stay after total knee arthroplasty, the main driving predictors of single-day length of stay after total knee arthroplasty were procedure or structural-related factors, including hospital site and surgeon. Understanding the risk factors that affect outcomes after total knee arthroplasty provides the opportunity to influence and potentially modify them favorably to optimize care.

Artroplastia do Joelho/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Fatores Etários , Idoso , Índice de Massa Corporal , Comorbidade , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais
Anesth Analg ; 120(2): 275-92, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25602448


The renin angiotensin system (RAS) is thought to be the body's main vasoconstrictor system, with physiological effects mediated via the interaction of angiotensin II with angiotensin I receptors (the "classic" RAS model). However, since the discovery of the heptapeptide angiotensin 1-7 and the development of the concept of the "alternate" RAS system, with its ability to reduce arterial blood pressure, our understanding of this physiologic system has changed dramatically. In this review, we focus on the newly discovered functions of the RAS, particularly the potential clinical significance of these developments, especially in the realm of new pharmacologic interventions for treating cardiovascular disease.

Fenômenos Fisiológicos Cardiovasculares , Homeostase/fisiologia , Sistema Renina-Angiotensina/fisiologia , Anti-Hipertensivos/farmacologia , Fenômenos Fisiológicos Cardiovasculares/efeitos dos fármacos , Homeostase/efeitos dos fármacos , Humanos , Sistema Renina-Angiotensina/efeitos dos fármacos