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1.
Georgian Med News ; (318): 19-23, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34628372

RESUMO

The goal of this study was to evaluate the efficacy of two common analgesic techniques: patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (IVPCA) in patients undergoing open colorectal surgeries. 130 patients were randomized in two groups: group I - n=65 (27 males, 38 females, age range 23-75) - whose postoperative period and pain was managed with PCEA; group II - n=65 (31 male, 34 female, age range 23-75) - whose postoperative period and pain was managed with IVPCA. There were no significant differences by demographic and preoperative factors between the groups. The study demonstrates, that both analgesia techniques in colorectal surgery patients, IVPCA and PCEA, resulted in high levels of satisfaction (as reflected by a median score of 4 on the 1-5 scale), and provided effective management of postoperative pain. There were no differences in the pain scores on the postoperative visual analogue scales, analgesic requirements and satisfaction score between groups. This indicates that IVPCA and Epidural PCA are equally effective to control the postoperative pain after open colorectal surgery.


Assuntos
Analgesia Epidural , Cirurgia Colorretal , Adulto , Idoso , Analgesia Controlada pelo Paciente , Analgésicos Opioides , Cirurgia Colorretal/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Adulto Jovem
3.
Zhen Ci Yan Jiu ; 46(7): 586-91, 2021 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-34369679

RESUMO

OBJECTIVE: To evaluate the therapeutic effect and safety of transcutaneous electrical acupoint stimulation (TEAS) on epidural-related maternal fever in parturients undergoing epidural labor analgesia. METHODS: A total of 198 primiparas with single birth, full-term pregnancy and head position were recruited and randomized into a TEAS group (98 cases) and a control group (100 cases). In the TEAS group, after epidural labor analgesia, TEAS was applied to bilateral Hegu (LI4) and Quchi (LI11), once an hour, for 30 min each time, till the end of childbirth. In the control group, after epidural labor analgesia, TEAS electrodes were attached to the same acupoints, but without electric stimulation. Maternal tympanic temperature and the score of Visual Analogue Score (VAS) were measured before analgesia, at 1, 2, 3, 4 and 5 h after analgesia and during labor respectively and maternal fever rate was evaluated in the parturients of two groups. Separately, before analgesia, 2 h after analgesia and during labor, the levels of serum interleukin (IL-6) and IL-1ß were determined in the parturients of two groups. The duration of labor, the mode of labor, oxytocin dosage, postpartum hemorrhage, neonatal Apgar scores, time of labor analgesia, labor analgesic consumption and adverse effects were recorded in the parturients of two groups. RESULTS: Maternal tympanic temperature increased progressively in two groups as analgesic time prolonged. Tympanic temperature at 3, 4 and 5 h after analgesia and du-ring labor, and maternal fever rate during labor in the TEAS group were all lower than those in the control group respectively (P<0.05). The levels of serum IL-6 and IL-1ß increased after analgesia in the parturients of two groups. The serum IL-6 level during labor and the level of IL-1ß at 2 h after analgesia and during labor in the parturients of the TEAS group were lower than those in the control group (P<0.05). The analgesic consumption in the TEAS group was less than that in the control group (P<0.05). The incidence of chills in the TEAS group was lower than that in the control group (P<0.05). The differences were not statistical in VAS score, duration of labor, mode of labor, oxytocin dosage, postpartum hemorrhage, time of labor analgesia and neonatal Apgar score, as well as the incidence of urine retention, nausea and vomiting and urinary retention between two groups (P>0.05). CONCLUSION: Transcutaneous electrical acupoint stimulation at LI11 and LI4 is conductive to relieving epidural-rela-ted maternal fever and reducing serum levels of IL-6 and IL-1ß in the parturients undergoing epidural labor analgesia. It is safe and effective in clinical application.


Assuntos
Analgesia Epidural , Trabalho de Parto , Estimulação Elétrica Nervosa Transcutânea , Pontos de Acupuntura , Analgésicos , Feminino , Humanos , Recém-Nascido , Gravidez
4.
Eur J Obstet Gynecol Reprod Biol ; 264: 259-265, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34340096

RESUMO

BACKGROUND: The purpose of this study was to explore the effects of combing Shangliao point injection with epidural analgesia on labor pain and birth process in women with low back pain and the possible mechanisms. METHODS: 93 consecutive women were randomized to receive either Shangliao point injection combined with epidural analgesia or epidural analgesia. Another 14 women were recruited to explore the mechanisms and the transperineal ultrasound was performed accordingly. RESULTS: The main result duration from epidural analgesia to baby delivery was significantly shorter in epidural analgesia and saline injection group than that in epidural analgesia group 307.0 (175.0-445.0) min VS 369.0 (254.0-563.0) min (P = 0.02). The verbal numerical rate scaling score in low back during the first contraction was significantly decreased 5.0 (4.0-7.0) after Shangliao point injections (P < 0.001). The consumption of ropivacaine per hour was significantly less in epidural analgesia and saline injection group than in epidural analgesia group (-0.4 mg, 95%CI: -0.1 to -1.8; P = 0.03). The angle of progression and anteroposterior diameter of the levator hiatus at rest and during valsalva were significantly increased after shangliao point injection (7.10°, 95%CI, 1.50~12.70; P = 0.02); (9.10°, 95%CI, 3.60~14.58; P < 0.01); (0.27 cm, 95%CI, 0.03~0.51; P = 0.03); (0.30 cm, 95%CI, 0.13~0.48; P < 0.01). CONCLUSIONS: Shangliao point injection could shorten the time to baby delivery and rapidly relieve low back pain in addition to epidural analgesia, that may attribute to its function of relaxing the pelvic floor muscles and promote fetal head progress.


Assuntos
Analgesia Epidural , Analgesia Obstétrica , Trabalho de Parto , Dor Lombar , Feminino , Humanos , Dor Lombar/tratamento farmacológico , Músculo Esquelético , Gravidez
5.
Eur J Anaesthesiol ; 38(9): 985-994, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34397527

RESUMO

BACKGROUND: Complex spinal procedures are associated with intense pain in the postoperative period. Adequate peri-operative pain management has been shown to correlate with improved outcomes including early ambulation and early discharge. OBJECTIVES: We aimed to evaluate the available literature and develop recommendations for optimal pain management after complex spine surgery. DESIGN AND DATA SOURCES: A systematic review using the PROcedure SPECific postoperative pain managemenT methodology was undertaken. Randomised controlled trials and systematic reviews published in the English language from January 2008 to April 2020 assessing postoperative pain after complex spine surgery using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. RESULTS: Out of 111 eligible studies identified, 31 randomised controlled trials and four systematic reviews met the inclusion criteria. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol, cyclo-oxygenase (COX)-2 specific-inhibitors or non-steroidal anti-inflammatory drugs (NSAIDs), intravenous ketamine infusion and regional analgesia techniques including epidural analgesia using local anaesthetics with or without opioids. Limited evidence was found for local wound infiltration, intrathecal and epidural opioids, erector spinae plane block, thoracolumbar interfascial plane block, intravenous lidocaine, dexmedetomidine and gabapentin. CONCLUSIONS: The analgesic regimen for complex spine surgery should include pre-operative or intra-operative paracetamol and COX-2 specific inhibitors or NSAIDs, continued postoperatively with opioids used as rescue analgesics. Other recommendations are intra-operative ketamine and epidural analgesia using local anaesthetics with or without opioids. Although there is procedure-specific evidence in favour of intra-operative methadone, it is not recommended as it was compared with shorter-acting opioids and due to its limited safety profile. Furthermore, the methadone studies did not use non-opioid analgesics, which should be the primary analgesics to ultimately reduce overall opioid requirements, including methadone. Further qualitative randomised controlled trials are required to confirm the efficacy and safety of these recommended analgesics on postoperative pain relief.


Assuntos
Analgesia Epidural , Manejo da Dor , Analgésicos Opioides , Anestésicos Locais , Humanos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia
7.
Artigo em Inglês | MEDLINE | ID: mdl-34444526

RESUMO

Patient-controlled epidural analgesia is widely used to control postoperative pain following major intra-abdominal surgeries. However, determining the optimal infusion dose that can produce effective analgesia while reducing side effects remains a task to be solved. Postoperative pain and adverse effects between variable-rate feedback infusion (VFIM group, n = 36) and conventional fixed-rate basal infusion (CFIM group, n = 36) of fentanyl/ropivacaine-based patient-controlled epidural analgesia were evaluated. In the CFIM group, the basal infusion rate was fixed (5 mL/h), whereas, in the VFIM group, the basal infusion rate was increased by 0.5 mL/h each time a bolus dose was administered and decreased by 0.3 mL/h when a bolus dose was not administered for 2 h. Patients in the VFIM group experienced significantly less pain at one to six hours after surgery than those in the CFIM group. Further, the number of patients who suffered from postoperative nausea was significantly lower in the VFIM group than in the CFIM group until six hours after surgery. The variable-rate feedback infusion mode of patient-controlled epidural analgesia may provide better analgesia accompanied with significantly less nausea in the early postoperative period than the conventional fixed-rate basal infusion mode following open gastrectomy.


Assuntos
Analgesia Epidural , Amidas , Analgésicos Opioides/uso terapêutico , Anestésicos Locais , Retroalimentação , Fentanila , Gastrectomia/efeitos adversos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos , Ropivacaina
8.
Sensors (Basel) ; 21(16)2021 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-34450771

RESUMO

Epidural analgesia represents a clinical common practice aiming at pain mitigation. This loco-regional technique is widely used in several applications such as labor, surgery and lower back pain. It involves the injections of anesthetics or analgesics into the epidural space (ES). The ES detection is still demanding and is usually performed by the techniques named loss of resistance (LOR). In this study, we propose a novel soft system (SS) based on one fiber Bragg grating sensor (FBG) embedded in a soft polymeric matrix for LOR detection during the epidural puncture. The SS was designed to allow instrumenting the syringe's plunger without relevant modifications of the anesthetist's sensations during the procedure. After the metrological characterization of the SS, we assessed the capability of this solution in detecting LOR by carrying it out in silico and in clinical settings. For both trials, results revealed the capability of the proposed solutions in detecting the LOR and then in recording the force exerted on the plunger.


Assuntos
Analgesia Epidural , Espaço Epidural , Simulação por Computador
9.
Anesthesiology ; 135(2): 218-232, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34195765

RESUMO

BACKGROUND: Delirium is a common and serious postoperative complication, especially in the elderly. Epidural anesthesia may reduce delirium by improving analgesia, reducing opioid consumption, and blunting stress response to surgery. This trial therefore tested the hypothesis that combined epidural-general anesthesia reduces the incidence of postoperative delirium in elderly patients recovering from major noncardiac surgery. METHODS: Patients aged 60 to 90 yr scheduled for major noncardiac thoracic or abdominal surgeries expected to last 2 h or more were enrolled. Participants were randomized 1:1 to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia with postoperative intravenous analgesia. The primary outcome was the incidence of delirium, which was assessed with the Confusion Assessment Method for the Intensive Care Unit twice daily during the initial 7 postoperative days. RESULTS: Between November 2011 and May 2015, 1,802 patients were randomized to combined epidural-general anesthesia (n = 901) or general anesthesia alone (n = 901). Among these, 1,720 patients (mean age, 70 yr; 35% women) completed the study and were included in the intention-to-treat analysis. Delirium was significantly less common in the combined epidural-general anesthesia group (15 [1.8%] of 857 patients) than in the general anesthesia group (43 [5.0%] of 863 patients; relative risk, 0.351; 95% CI, 0.197 to 0.627; P < 0.001; number needed to treat 31). Intraoperative hypotension (systolic blood pressure less than 80 mmHg) was more common in patients assigned to epidural anesthesia (421 [49%] vs. 288 [33%]; relative risk, 1.47, 95% CI, 1.31 to 1.65; P < 0.001), and more epidural patients were given vasopressors (495 [58%] vs. 387 [45%]; relative risk, 1.29; 95% CI, 1.17 to 1.41; P < 0.001). CONCLUSIONS: Older patients randomized to combined epidural-general anesthesia for major thoracic and abdominal surgeries had one third as much delirium but 50% more hypotension. Clinicians should consider combining epidural and general anesthesia in patients at risk of postoperative delirium, and avoiding the combination in patients at risk of hypotension.


Assuntos
Analgesia Epidural/métodos , Anestesia Geral/métodos , Delírio do Despertar/epidemiologia , Avaliação Geriátrica/métodos , Procedimentos Cirúrgicos Operatórios , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Quimioterapia Combinada , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade
10.
Anesthesiology ; 135(2): 233-245, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34195784

RESUMO

BACKGROUND: Experimental and observational research suggests that combined epidural-general anesthesia may improve long-term survival after cancer surgery by reducing anesthetic and opioid consumption and by blunting surgery-related inflammation. This study therefore tested the primary hypothesis that combined epidural-general anesthesia improves long-term survival in elderly patients. METHODS: This article presents a long-term follow-up of patients enrolled in a previous trial conducted at five hospitals. Patients aged 60 to 90 yr and scheduled for major noncardiac thoracic and abdominal surgeries were randomly assigned to either combined epidural-general anesthesia with postoperative epidural analgesia or general anesthesia alone with postoperative intravenous analgesia. The primary outcome was overall postoperative survival. Secondary outcomes included cancer-specific, recurrence-free, and event-free survival. RESULTS: Among 1,802 patients who were enrolled and randomized in the underlying trial, 1,712 were included in the long-term analysis; 92% had surgery for cancer. The median follow-up duration was 66 months (interquartile range, 61 to 80). Among patients assigned to combined epidural-general anesthesia, 355 of 853 (42%) died compared with 326 of 859 (38%) deaths in patients assigned to general anesthesia alone: adjusted hazard ratio, 1.07; 95% CI, 0.92 to 1.24; P = 0.408. Cancer-specific survival was similar with combined epidural-general anesthesia (327 of 853 [38%]) and general anesthesia alone (292 of 859 [34%]): adjusted hazard ratio, 1.09; 95% CI, 0.93 to 1.28; P = 0.290. Recurrence-free survival was 401 of 853 [47%] for patients who had combined epidural-general anesthesia versus 389 of 859 [45%] with general anesthesia alone: adjusted hazard ratio, 0.97; 95% CI, 0.84 to 1.12; P = 0.692. Event-free survival was 466 of 853 [55%] in patients who had combined epidural-general anesthesia versus 450 of 859 [52%] for general anesthesia alone: adjusted hazard ratio, 0.99; 95% CI, 0.86 to 1.12; P = 0.815. CONCLUSIONS: In elderly patients having major thoracic and abdominal surgery, combined epidural-general anesthesia with epidural analgesia did not improve overall or cancer-specific long-term mortality. Nor did epidural analgesia improve recurrence-free survival. Either approach can therefore reasonably be selected based on patient and clinician preference.


Assuntos
Analgesia Epidural/mortalidade , Anestesia Geral/mortalidade , Avaliação Geriátrica/métodos , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Idoso de 80 Anos ou mais , Analgesia Epidural/métodos , Anestesia Geral/métodos , China/epidemiologia , Quimioterapia Combinada , Feminino , Seguimentos , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Sobrevida
12.
Acta Med Port ; 34(4): 272-277, 2021 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-34214419

RESUMO

INTRODUCTION: In the current century, increasing importance has been given to the opinions, expectations and experiences of women using healthcare services. The fulfillment of expectations is determined by satisfaction. This study aims to analyze both expectations and satisfaction during childbirth regarding labor epidural analgesia among parturients, with a focus on myths. MATERIAL AND METHODS: A prospective observational study was conducted in parturients at the Centro Hospitalar Universitário Lisboa Norte - Santa Maria Hospital in Lisbon, Portugal, applying a questionnaire to 317 random women. SPSS v22.0 was used for data analysis. RESULTS: Three hundred questionnaires were returned, from women with a mean age of 31. Among the respondents, 46.3% had a college degree and 64% were employed, 46% were primiparas and only 14% had a previous anesthesiology appointment for childbirth purposes. The overall degree of satisfaction surrounding the birth experience was good/excellent for 87% of women. Labor epidural analgesia was performed on 96% of all patients, with an excellent/good outcome for 82.1% and a higher than expected results for 40.7% of them. Regarding the myths, 52.5% believed that epidural analgesia imposes a dose limit and 58.9% that it often causes permanent back pain. The level of education was significantly associated with some myths (p < 0.05), since women with a higher level of education do not believe most of them. DISCUSSION: This study supports the need for an evaluation of the current information that women have about labor epidural analgesia/childbirth. Women's individual needs can be met by multidisciplinary teams including Anesthesiology specialists. CONCLUSION: Maternal satisfaction with childbirth and analgesia is a complex and dynamic process that includes and is not limited to the relief of pain.


Assuntos
Analgesia Epidural/efeitos adversos , Dor do Parto/psicologia , Trabalho de Parto , Parto/psicologia , Satisfação do Paciente , Adulto , Analgesia Obstétrica , Estudos Transversais , Feminino , Humanos , Trabalho de Parto/psicologia , Pessoa de Meia-Idade , Motivação , Satisfação Pessoal , Portugal , Gravidez , Estudos Prospectivos , Centros de Atenção Terciária
13.
Cochrane Database Syst Rev ; 7: CD013321, 2021 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-34231203

RESUMO

BACKGROUND: Many women experience fear of childbirth (FOC). While fears about childbirth may be normal during pregnancy, some women experience high to severe FOC. At the extreme end of the fear spectrum is tocophobia, which is considered a specific condition that may cause distress, affect well-being during pregnancy and impede the transition to parenthood. Various interventions have been trialled, which support women to reduce and manage high to severe FOC, including tocophobia. OBJECTIVES: To investigate the effectiveness of non-pharmacological interventions for reducing fear of childbirth (FOC) compared with standard maternity care in pregnant women with high to severe FOC, including tocophobia. SEARCH METHODS: In July 2020, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We contacted researchers of trials which were registered and appeared to be ongoing. SELECTION CRITERIA: We included randomised clinical trials which recruited pregnant women with high or severe FOC (as defined by the individual trial), for treatment intended to reduce FOC. Two review authors independently screened and selected titles and abstracts for inclusion. We excluded quasi-randomised and cross-over trials. DATA COLLECTION AND ANALYSIS: We used standard methodological approaches as recommended by Cochrane. Two review authors independently extracted data and assessed the studies for risk of bias. A third review author checked the data analysis for accuracy. We used GRADE to assess the certainty of the evidence. The primary outcome was a reduction in FOC. Secondary outcomes were caesarean section, depression, birth preference for caesarean section or spontaneous vaginal delivery, and epidural use. MAIN RESULTS: We included seven trials with a total of 1357 participants. The interventions included psychoeducation, cognitive behavioural therapy, group discussion, peer education and art therapy. We judged four studies as high or unclear risk of bias in terms of allocation concealment; we judged three studies as high risk in terms of incomplete outcome data; and in all studies, there was a high risk of bias due to lack of blinding. We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision and inconsistency. None of the studies reported data about women's anxiety. Participating in non-pharmacological interventions may reduce levels of fear of childbirth, as measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ), but the reduction may not be clinically meaningful (mean difference (MD) -7.08, 95% confidence interval (CI) -12.19 to -1.97; 7 studies, 828 women; low-certainty evidence). The W-DEQ tool is scored from 0 to 165 (higher score = greater fear). Non-pharmacological interventions probably reduce the number of women having a caesarean section (RR 0.70, 95% CI 0.55 to 0.89; 5 studies, 557 women; moderate-certainty evidence). There may be little to no difference between non-pharmacological interventions and usual care in depression scores measured with the Edinburgh Postnatal Depression Scale (EPDS) (MD 0.09, 95% CI -1.23 to 1.40; 2 studies, 399 women; low-certainty evidence). The EPDS tool is scored from 0 to 30 (higher score = greater depression). Non-pharmacological interventions probably lead to fewer women preferring a caesarean section (RR 0.37, 95% CI 0.15 to 0.89; 3 studies, 276 women; moderate-certainty evidence).  Non-pharmacological interventions may increase epidural use compared with usual care, but the 95% CI includes the possibility of a slight reduction in epidural use (RR 1.21, 95% CI 0.98 to 1.48; 2 studies, 380 women; low-certainty evidence). AUTHORS' CONCLUSIONS: The effect of non-pharmacological interventions for women with high to severe fear of childbirth in terms of reducing fear is uncertain. Fear of childbirth, as measured by W-DEQ, may be reduced but it is not certain if this represents a meaningful clinical reduction of fear. There may be little or no difference in depression, but there may be a reduction in caesarean section delivery. Future trials should recruit adequate numbers of women and measure birth satisfaction and anxiety.


Assuntos
Medo/psicologia , Parto/psicologia , Transtornos Fóbicos/terapia , Analgesia Epidural/psicologia , Analgesia Epidural/estatística & dados numéricos , Analgesia Obstétrica/psicologia , Analgesia Obstétrica/estatística & dados numéricos , Terapia pela Arte , Viés , Cesárea/psicologia , Cesárea/estatística & dados numéricos , Terapia Cognitivo-Comportamental , Aconselhamento , Depressão/epidemiologia , Feminino , Humanos , Tocologia , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
14.
Br J Hosp Med (Lond) ; 82(5): 1-2, 2021 May 02.
Artigo em Inglês | MEDLINE | ID: mdl-34076512

RESUMO

Epidurals are considered the gold standard for labour analgesia. The possibility of newer pumps reducing staff workload has reignited interest in the advantages of the intermittent bolus technique, but is this superior to a continuous epidural infusion?


Assuntos
Analgesia Epidural , Analgesia Obstétrica , Anestesia Epidural , Analgesia Controlada pelo Paciente , Analgésicos , Anestésicos Locais , Humanos
15.
World J Surg ; 45(10): 3165-3173, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34185150

RESUMO

BACKGROUND: This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes. METHODS: MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use. RESULTS: Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD. CONCLUSIONS: EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.


Assuntos
Analgesia Epidural , Pancreatectomia , Analgesia Controlada pelo Paciente , Analgésicos/uso terapêutico , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pancreatectomia/efeitos adversos , Estudos Retrospectivos
16.
Anesthesiology ; 135(3): 419-432, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34192298

RESUMO

BACKGROUND: Regional anesthesia and analgesia reduce the stress response to surgery and decrease the need for volatile anesthesia and opioids, thereby preserving cancer-specific immune defenses. This study therefore tested the primary hypothesis that combining epidural anesthesia-analgesia with general anesthesia improves recurrence-free survival after lung cancer surgery. METHODS: Adults scheduled for video-assisted thoracoscopic lung cancer resections were randomized 1:1 to general anesthesia and intravenous opioid analgesia or combined epidural-general anesthesia and epidural analgesia. The primary outcome was recurrence-free survival (time from surgery to the earliest date of recurrence/metastasis or all-cause death). Secondary outcomes included overall survival (time from surgery to all-cause death) and cancer-specific survival (time from surgery to cancer-specific death). Long-term outcome assessors were blinded to treatment. RESULTS: Between May 2015 and November 2017, 400 patients were enrolled and randomized to general anesthesia alone (n = 200) or combined epidural-general anesthesia (n = 200). All were included in the analysis. The median follow-up duration was 32 months (interquartile range, 24 to 48). Recurrence-free survival was similar in each group, with 54 events (27%) with general anesthesia alone versus 48 events (24%) with combined epidural-general anesthesia (adjusted hazard ratio, 0.90; 95% CI, 0.60 to 1.35; P = 0.608). Overall survival was also similar with 25 events (13%) versus 31 (16%; adjusted hazard ratio, 1.12; 95% CI, 0.64 to 1.96; P = 0.697). There was also no significant difference in cancer-specific survival with 24 events (12%) versus 29 (15%; adjusted hazard ratio, 1.08; 95% CI, 0.61 to 1.91; P = 0.802). Patients assigned to combined epidural-general had more intraoperative hypotension: 94 patients (47%) versus 121 (61%; relative risk, 1.29; 95% CI, 1.07 to 1.55; P = 0.007). CONCLUSIONS: Epidural anesthesia-analgesia for major lung cancer surgery did not improve recurrence-free, overall, or cancer-specific survival compared with general anesthesia alone, although the CI included both substantial benefit and harm.


Assuntos
Analgesia Epidural/métodos , Anestesia Epidural/métodos , Neoplasias Pulmonares/cirurgia , Dor Pós-Operatória/prevenção & controle , Cirurgia Torácica Vídeoassistida/efeitos adversos , Idoso , Analgesia Epidural/mortalidade , Analgésicos Opioides/administração & dosagem , Anestesia Epidural/mortalidade , Anestesia Geral/métodos , Anestesia Geral/mortalidade , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/mortalidade , Cirurgia Torácica Vídeoassistida/métodos
18.
Gynecol Obstet Invest ; 86(3): 231-238, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34192701

RESUMO

PURPOSE: The study was aimed to systematically assess the effect and safety of remifentanil patient-controlled analgesia (rPCA) versus epidural analgesia (EA) during labor. METHODS: Eligible trials were retrieved from PubMed, EMBASE, ScienceDirect, and Cochrane Library before April 2020. The primary outcomes were patient satisfaction with pain relief and average visual analog scale (VAS) pain scores during labor; the secondary outcomes were rate of spontaneous delivery, oxygen desaturation, maternal hyperthermia, and neonatal Apgar scores <7 at 1 and 5 min. RESULTS: Eleven studies involving 3,039 parturients were included. We found that parturients receiving rPCA were similarly satisfied with pain relief compared to those receiving EA (standardized mean difference: -0.19; 95% confidence interval [CI]: -0.57, 0.18), though had significantly higher VAS pain scores during labor (weighted mean difference: 1.41; 95% CI: 0.32, 2.50). The rate of spontaneous delivery was comparable. rPCA increased the risk of maternal oxygen desaturation (risk ratio [RR]:3.23, 95% CI: 1.98, 5.30). There was no statistical significance regarding hyperthermia (RR: 0.49, 95% CI: 0.24, 1.01). No significant difference was found for neonatal Apgar scores <7 at 1 and 5 min. CONCLUSION: rPCA could be an optional alternative for pain relief to EA without worsening maternal satisfaction with pain relief, delivery modes, or neonatal morbidity. However, rPCA was associated with higher pain intensity during labor and higher incidence of maternal oxygen desaturation. The routine use of rPCA in labor must be armed with close respiratory monitoring. Continued well-designed studies are required to provide more robust evidence.


Assuntos
Analgesia Epidural , Analgesia Obstétrica , Dor do Parto , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Analgesia Controlada pelo Paciente , Feminino , Humanos , Recém-Nascido , Dor do Parto/tratamento farmacológico , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Remifentanil
19.
Ann Surg Oncol ; 28(11): 6321-6328, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34050429

RESUMO

BACKGROUND: For esophagectomy, thoracic epidural analgesia (TEA) is the standard of care for perioperative pain management. Although effective, TEA is associated with moderate to serious adverse events such as hypotension and neurologic complications. Paravertebral analgesia (PVA) may be a safe alternative. The authors hypothesized that TEA and PVA are similar in efficacy for pain treatment in thoracolaparoscopic Ivor Lewis esophagectomy. METHODS: This retrospective cohort study compared TEA with PVA in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In this study, TEA consisted of continuous epidural bupivacaine and sufentanil infusion with a patient-controlled bolus function. In PVA, the catheter was inserted by the surgeon under thoracoscopic vision during surgery. Administration of PVA consisted of continuous paravertebral bupivacaine infusion after a bolus combined with patient-controlled analgesia using intravenous morphine. The primary outcome was the median highest recorded Numeric Pain Rating Scale (NRS) during the 3 days after surgery. The secondary outcomes were vasopressor consumption, fluid administration, and length of hospital stay. RESULTS: In both groups, the median highest recorded NRS was 4 or lower during the first three postoperative days. The patients with PVA had a higher overall NRS (mean difference, 0.75; 95% confidence interval 0.49-1.44). No differences were observed in any of the other secondary outcomes. CONCLUSION: For the patients undergoing thoracolaparoscopic Ivor Lewis esophagectomy, TEA was superior to PVA, as measured by NRS during the first three postoperative days. However, both modes provided adequate analgesia, with a median highest recorded NRS of 4 or lower. These results could form the basis for a randomized controlled trial.


Assuntos
Analgesia Epidural , Esofagectomia , Analgesia Epidural/efeitos adversos , Esofagectomia/efeitos adversos , Humanos , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos
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