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1.
Medicine (Baltimore) ; 99(27): e20765, 2020 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-32629656

RESUMO

BACKGROUND: Remimazolam is a newly developed benzodiazepine as an alternative of conventional sedatives in the procedure of anesthesia. For the purpose of evaluating the efficacy and safety of remimazolam sedation during an endoscopy, we will perform a systematic review and meta-analysis of randomized controlled trials that compared remimazolam with midazolam and/or placebo. METHODS: We will search PubMed, Embase, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) from inception to December 2019 for randomized controlled trials that investigated efficacy and safety of remimazolam during an endoscopy. The job will be performed without language restriction. Experimental groups will include the interventions of remimazolam, while control groups will involve midazolam, placebo, or no controls. The primary outcome will be the onset time, followed by the secondary outcomes of the recovery time, the incidence of hypotension, the incidence of hypoxia and the incidence of bradycardia. Relative ratio or standardized mean difference will be used to measure the effect size of remimazolam. We will use I statistics to assess the between-study heterogeneity in each meta-analysis, Eager's test to detect publication bias. RESULTS: The results of this study will be published in a peer-reviewed journal. ETHICS AND DISSEMINATION: There is no need for ethical approval because all data used in this meta-analysis have been published. In addition, all data will be analyzed anonymously during the review process. PROTOCOL REGISTRATION NUMBER: CRD42020170745.


Assuntos
Analgesia/métodos , Benzodiazepinas , Sedação Consciente/métodos , Hipnóticos e Sedativos , Analgesia/efeitos adversos , Benzodiazepinas/efeitos adversos , Sedação Consciente/efeitos adversos , Humanos , Hipnóticos e Sedativos/efeitos adversos
2.
Anaesth Crit Care Pain Med ; 39(3): 395-415, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32512197

RESUMO

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.


Assuntos
Analgesia/normas , Anestesia/normas , Betacoronavirus , Infecções por Coronavirus , Controle de Infecções/normas , Pandemias , Pneumonia Viral , Adulto , Manuseio das Vias Aéreas , Analgesia/efeitos adversos , Analgesia/métodos , Anestesia/efeitos adversos , Anestesia/métodos , Criança , Técnicas de Laboratório Clínico , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Procedimentos Clínicos , Infecção Hospitalar/prevenção & controle , Infecção Hospitalar/transmissão , Desinfecção , Procedimentos Cirúrgicos Eletivos , Contaminação de Equipamentos/prevenção & controle , Acesso aos Serviços de Saúde , Humanos , Controle de Infecções/métodos , Consentimento Livre e Esclarecido , Doenças Profissionais/prevenção & controle , Salas Cirúrgicas/normas , Pandemias/prevenção & controle , Isolamento de Pacientes , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Cuidados Pré-Operatórios , Comitê de Profissionais , Risco , Avaliação de Sintomas , Precauções Universais
3.
J Anesth Hist ; 6(2): 74-78, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32593380

RESUMO

Sunday February 24, 1957 was a pivotal day in the history of anesthesiology and pain medicine. The leader of the Roman Catholic Church, Pope Pius XII met with anesthesiologists attending an international symposium sponsored by the Italian Society of Anesthesiologists entitled, "Anesthesia and the Human Personality". The purpose of this audience was to seek clarification about the use of opioids at the end of life to reduce suffering. Three questions had been formulated from the previous year's Italian Congress of Anesthesiologists and sent to the Holy See on this specific issue. The Pope responded during this audience remarking that there was no moral obligation to withhold pain medication that could elevate suffering. He further remarked that the suppression of consciousness that can occur with opioids was consistent with the spirit of the Christian gospels. Finally, he also stated that it was not morally objectionable to administer opioids even if it might shorten life. The moral philosophy behind these answers is the doctrine of double effect. In essence, administering medications to relieve pain, the primary effect, may also hasten death, the unintended secondary effect. In seeking answers to these questions, the Italian anesthesiologists were at the forefront of a larger and ongoing debate. As new therapies are developed that may have unintended consequences, when it is morally permissible to use them?


Assuntos
Analgesia/história , Anestesiologia/história , Catolicismo/história , Manejo da Dor/história , Religião e Medicina , Analgesia/efeitos adversos , Analgesia/ética , Anestesiologistas/história , Anestesiologia/ética , História do Século XX , Humanos , Itália , Manejo da Dor/efeitos adversos , Sociedades Médicas/história
4.
Expert Opin Pharmacother ; 21(8): 905-916, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32156151

RESUMO

INTRODUCTION: Postoperative delirium is a common sequela in older adults in the peri-operative period leading to poor outcomes with a complex pathophysiology which has led to a variety of different pharmacologic agents employed in attempts to prevent and treat this syndrome. No pharmacologic agent has been approved to treat this disorder, but this review discusses the pharmacologic strategies which have been tried based on the hypotheses of the causation of the syndrome including neurotransmitter imbalance, inflammation, and oxidative stress. AREAS COVERED: Systematic reviews and meta-analyses of randomized clinical trials (RCTs) were included via search of electronic databases specifically for the terms postoperative delirium and pharmacologic treatments. With this approach, the recurrent topics of analgesia and sedation, antipsychotics, acetylcholinesterase inhibitors (AchE-Is), inflammation, and melatonin were emphasized and provided the outline for this review. EXPERT OPINION: Research evidence does not support any particular agent in any of the pharmacologic classes reviewed. However, there is some potential benefit with dexmedetomidine, melatonin, and the monitoring of anesthetic agents all of which need further clinical trials to validate these conclusions. Exploration of ways to improve studies and the application of novel pharmacologic agents may offer future benefit.


Assuntos
Antipsicóticos/uso terapêutico , Delírio/tratamento farmacológico , Dexmedetomidina/uso terapêutico , Melatonina/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Idoso , Analgesia/efeitos adversos , Analgesia/métodos , Anestesia/efeitos adversos , Anestesia/métodos , Delírio/etiologia , Monitoramento de Medicamentos , Humanos , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto
5.
PLoS One ; 15(1): e0227204, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31945076

RESUMO

OBJECTIVE: To describe how small animal anaesthesia is performed in French-speaking Eastern Canada, and the variations between practices, in particular based on practice type, veterinarian gender and experience. DESIGN: Observational study, survey. SAMPLE: 156 respondents. PROCEDURE: A questionnaire was designed to assess current small animal anaesthesia practices in French-speaking Eastern Canada, mainly in the province of Quebec. The questionnaire was available through SurveyMonkey, and consisted of four parts: demographic information about the veterinarians surveyed, evaluation and management of anaesthetic risk, anaesthesia procedure, monitoring and safety. Gender, year of graduation, and type of practice were tested as potential risk factors. Chi-square exact test was used to study relations between each risk factor, and the effect of the selected risk factor on each response of the survey. For ordinal data, the Cochran-Mantel-Haenszel test was used to maximize power. RESULTS: Response rate over a period of 3 months was 20.85% (156 respondents). Overall, the way anaesthesia is performed by most respondents does not meet international guidelines, such as patient preparation and evaluation prior to anaesthesia, not using individualised protocols (for 41%), not obtaining intravenous access (12.4% use it for all their anaesthesia in cats, and 30.6% in dogs), lack of patient monitoring at certain intervals for 55% of the responses, and client prompted optional analgesia (for 29% of respondents). Some practices are more compliant than others. Among them, referral centres generally offer better care than general practices. CONCLUSIONS AND CLINICAL RELEVANCE: The level of care in anaesthesia and analgesia in practices in French-speaking Eastern Canada is concerning, highlighting the need for more sustained continuing education.


Assuntos
Analgesia/veterinária , Anestesia/veterinária , Analgesia/efeitos adversos , Analgesia/métodos , Anestesia/efeitos adversos , Anestesia/métodos , Animais , Gatos , Cães , Feminino , Humanos , Masculino , Quebeque , Inquéritos e Questionários , Médicos Veterinários
7.
Einstein (Sao Paulo) ; 18: eAO5168, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31994609

RESUMO

OBJECTIVE: To understand the use of tools, protocols and comfort measures related to sedation/analgesia, and to screen the occurrence of delirium in pediatric intensive care units. METHODS: A survey with 14 questions was distributed by e-mail to Brazilian critical care pediatricians. Eight questions addressed physician and hospital demographics, and six inquired practices to assess sedation, analgesia, and delirium in pediatric intensive care units. RESULTS: Of 373 questionnaires sent, 61 were answered (16.3%). The majority of physicians were practicing in the Southeast region (57.2%). Of these, 46.5% worked at public hospitals, 28.6% of which under direct state administration. Of respondents, 57.1% used formal protocols for sedation and analgesia, and the Ramsay scale was the most frequently employed (52.5%). Delirium screening scores were not used by 48.2% of physicians. The Cornell Assessment of Pediatric Delirium was the score most often used (23.2%). The majority (85.7%) of physicians did not practice daily sedation interruption, and only 23.2% used non-pharmacological measures for patient comfort frequently, with varied participation of parents in the process. CONCLUSION: This study highlights the heterogeneity of practices for assessment of sedation/analgesia and lack of detection of delirium among critical care pediatricians in Brazil.


Assuntos
Analgesia/métodos , Sedação Profunda/métodos , Delírio/diagnóstico , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Pediatras/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Analgesia/efeitos adversos , Analgesia/estatística & dados numéricos , Brasil , Sedação Profunda/efeitos adversos , Sedação Profunda/estatística & dados numéricos , Delírio/etiologia , Humanos , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Inquéritos e Questionários
8.
Emerg Med J ; 37(2): 73-78, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31831589

RESUMO

Trauma in the elderly (>65 years) is an increasingly common presentation to the ED. A fall from standing height is the most common mechanism after which such patients present, and rib fracture is the most common non-spinal fracture. Thoracic injury in patients aged over 65 is associated with significant morbidity and mortality. There are currently no universally applied guidelines for assessment, investigation and management of such patients. In this expert practice review, we discuss the evidence base and options for clinical management in this vulnerable patient group.


Assuntos
Geriatria/métodos , Guias de Prática Clínica como Assunto , Traumatismos Torácicos/terapia , Ferimentos não Penetrantes/terapia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Analgesia/efeitos adversos , Analgesia/métodos , Feminino , Geriatria/normas , Geriatria/tendências , Humanos , Masculino
9.
Medicine (Baltimore) ; 98(41): e17503, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593120

RESUMO

BACKGROUND: The local injection of multimodal cocktail is currently commonly used in the treatment of postoperative pain after total knee arthroplasty (TKA). It is still inconclusive whether the morphine added to the intraoperative injection mixture could make some difference. This meta-analysis aimed to evaluate the efficacy and safety of additional morphine injection on postoperative analgesia in TKA, and provide some useful information on morphine usage in clinical practice. METHODS: The randomized controlled trials (RCTs) in databases including PubMed, Web of Science, Embase, Cochrane Library, Chinese biomedical literature database (CBM), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched. Of 623 records identified, 8 RCTs involving 1093 knees were eligible for data extraction and meta-analysis according to criteria included. RESULTS: Meta-analysis showed that the use of local morphine injection was not associated with significant pain relief within 48 hours postoperatively at rest and on motion (P > .05, all). The use of morphine reduced postoperative total systemic opioids consumption (P < .05). This study found no significant differences in other outcomes including knee flexion range of motion (ROM) (P > .05), extension ROM (P > .05), The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (P > .05), Post-operative nausea and vomiting occurrence (P > .05) regardless of the presence of morphine or not in the injections. CONCLUSION: Additional morphine added to multimodal cocktail did not decrease the postoperative pain scores significantly based on our outcomes, but it reduced the systemic postoperative opioids consumption in total knee arthroplasty.


Assuntos
Analgesia/métodos , Artroplastia do Joelho/efeitos adversos , Morfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Analgesia/efeitos adversos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestesia Local/métodos , Artroplastia do Joelho/métodos , Terapia Combinada/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Medição da Dor/efeitos dos fármacos , Medição da Dor/métodos , Náusea e Vômito Pós-Operatórios/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Amplitude de Movimento Articular/efeitos dos fármacos
10.
Intensive Crit Care Nurs ; 54: 7-14, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31395447

RESUMO

OBJECTIVES: To assess the impact of analgosedation on mortality and delirium in critically ill patients. RESEARCH METHODOLOGY: A systematic review and meta-analysis was conducted to identify studies through Pubmed, Cochrane Library, Embase and Web of Science published from June 2017 to July 2018. Only articles published in English were considered. The Cochrane Collaboration Risk of Bias Tool was used to evaluate the methodological quality of randomised trials, while Newcastle-Ottawa Scale (NOS) was used for cohort studies. RESULTS: Seventeen eligible studies were identified, including 2298 patients (1170 in the experimental group and 1128 in the control group). Varying analgesics and sedatives were investigated, showing a high clinical heterogeneity. Analgosedation significantly decreased the ICU mortality rate when compared to conventional analgesia and sedation [odds ratio (OR) 0.72, 95%CI 0.53-0.97; P = 0.03]. No significant difference was demonstrated in 28-day/hospital mortality rate [OR 0.91, 95%CI 0.70-1.18; P = 0.48] or in the incidence of delirium [OR 1.06, 95%CI 0.78-1.45; P = 0.70]. However, subgroup analysis of trials indicated a significant increase in the delirium rate (OR: 1.88, 95%CI 1.14-3.10, p = 0.01). CONCLUSION: The ICU mortality was decreased by implementing analgosedation, but the hospital mortality and the delirium rates were not. Because of the absence of higher quality study designs, clinical heterogeneity and inclusion of small number of studies, the analysis results must be cautiously interpreted.


Assuntos
Analgesia/efeitos adversos , Delírio/etiologia , Mortalidade Hospitalar/tendências , Analgesia/métodos , Delírio/epidemiologia , Delírio/fisiopatologia , Humanos , Unidades de Terapia Intensiva/organização & administração
11.
Curr Opin Anaesthesiol ; 32(5): 674-682, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31356362

RESUMO

PURPOSE OF REVIEW: Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery. RECENT FINDINGS: Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking. SUMMARY: New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.


Assuntos
Analgesia/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/terapia , Assistência Perioperatória/métodos , Analgesia/efeitos adversos , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Humanos , Bloqueio Nervoso/efeitos adversos , Epidemia de Opioides/etiologia , Epidemia de Opioides/prevenção & controle , Dor Pós-Operatória/etiologia , Assistência Perioperatória/efeitos adversos , Resultado do Tratamento
12.
Curr Opin Anaesthesiol ; 32(5): 629-634, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31335335

RESUMO

PURPOSE OF REVIEW: Gabapentinoid use has increased substantially in the past several years after initial promising data with regard to acute perioperative pain control. The purpose of this review is to critically appraise the evidence for the use of gabapentinoids for acute pain management and its impact on the development of chronic pain after surgery. RECENT FINDINGS: Recent meta-analyses have revealed that prior data likely have overestimated the beneficial effects of gabapentinoids in acute perioperative pain while underestimating the associated adverse effects. The utility of gabapentinoids in the setting of enhanced recovery pathways and for the prevention of chronic postsurgical pain is still unclear. Moreover, there has been increasing concern regarding the potential for misuse and abuse of gabapentinoids. SUMMARY: Current evidence does not support the routine use of gabapentinoids as part of a multimodal analgesic regimen in enhanced recovery pathways. We recommend being selective with regard to using gabapentinoids for acute postoperative pain management after careful consideration of the potential side effect profile based on patient comorbidities as well as the expected severity of postoperative pain. Large, high-quality trials are needed to identify the impact of gabapentinoids in the context of multimodal anagelsia.


Assuntos
Analgesia/efeitos adversos , Analgésicos/efeitos adversos , Gabapentina/efeitos adversos , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Dor Aguda/diagnóstico , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Analgesia/métodos , Analgésicos/administração & dosagem , Dor Crônica/diagnóstico , Dor Crônica/tratamento farmacológico , Dor Crônica/etiologia , Recuperação Pós-Cirúrgica Melhorada , Gabapentina/administração & dosagem , Gabapentina/análogos & derivados , Humanos , Metanálise como Assunto , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/efeitos adversos
13.
Curr Opin Anaesthesiol ; 32(5): 592-599, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31306155

RESUMO

PURPOSE OF REVIEW: To explore the data for and against the use of the various components of multimodal analgesia in cranial neurosurgery. RECENT FINDINGS: Postcraniotomy pain is a challenging clinical problem in that analgesia must be accomplished without affecting neurologic function (i.e. 'losing the neurologic exam'). The traditional approach with low-dose opioids is often insufficient and can cause well recognized side effects. Newer multimodal analgesic approaches have proven beneficial in a variety of other surgical patient populations. The combined use of multiple nonopioid analgesics offers the promise of improved pain control and reduced opioid administration, while preserving the clinical neurologic exam. Specifically, acetaminophen and gabapentinoids should be considered for craniotomy patients, both preoperatively and postoperatively. The gabapentinoids have the added benefit of reduced nausea. Scalp blocks have moderate quality evidence supporting their use over incisional infiltration alone, with analgesia that extends into the postoperative period. Intraoperative dexmedetomidine reduces postoperative opioid requirements with the added benefit of reduced postcraniotomy hypertension. Methocarbamol, NSAIDs [both nonspecific cyclooxygenase (COX) 1 and 2 inhibitors and specific COX-2 inhibitors], ketamine, and intravenous lidocaine require further data regarding safety and efficacy in craniotomy patients. SUMMARY: Opioids are the mainstay for treating acute postcraniotomy pain but should be minimized. The evidence to support a multimodal approach is growing; neuroanesthesiologists and neurosurgeons should seek to incorporate multimodal analgesia into the perioperative care of craniotomy patients. Preoperative and postoperative gabapentin and acetaminophen, intraoperative dexmedetomidine, and scalp blocks over incisional infiltration have the most data for benefit, with good safety profiles. Further research is needed to define the safety, efficacy, and dosing parameters for NSAIDs including COX-2 inhibitors, methocarbamol, ketamine, and intravenous lidocaine in cranial neurosurgery.


Assuntos
Analgesia/métodos , Craniotomia/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Equipe de Assistência ao Paciente/organização & administração , Analgesia/efeitos adversos , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos não Entorpecentes/efeitos adversos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesiologistas/organização & administração , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Doenças do Sistema Nervoso Central/diagnóstico , Doenças do Sistema Nervoso Central/etiologia , Medicina Baseada em Evidências/métodos , Humanos , Bloqueio Nervoso/métodos , Neurocirurgiões/organização & administração , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/etiologia , Segurança do Paciente , Assistência Perioperatória/métodos , Resultado do Tratamento
14.
Curr Opin Anaesthesiol ; 32(3): 285-290, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045635

RESUMO

PURPOSE OF REVIEW: The objective of this review is to analyze and summarize the current anesthetic methods used to alleviate pain and discomfort during transvaginal oocyte retrieval procedures (TORP), to try to reach practical recommendations, based on the evidence, which will translate into daily practice, the knowledge on the anesthetic management of patients scheduled for TORP. RECENT FINDINGS: There is no strong evidence to recommend the avoidance of any technique or drug for TORP, including nitrous oxide or halogenated agents. Women should be offered any available technique. The evidence available up to date is not convincing enough to recommend avoiding any anesthetic technique in terms of pregnancy and birth rates. SUMMARY: TORP is painful for women and different techniques may be used for pain relief in day case surgery. The other important outcome to consider is the pregnancy rate, and any anesthetic technique or drug which would improve this pregnancy rate should be recommended. Conscious sedation and general anesthesia proved to be well tolerated for woman and the oocytes, despite the use of propofol, opioids, benzodiacepines, nitrous oxide, or other drugs. Spinal anesthesia and paracervical block are also acceptable options, and can be combined with conscious sedation. Nevertheless, more studies are needed to find out the ideal drug or technique combination for the woman and the oocyte.


Assuntos
Analgesia/normas , Anestesia/normas , Sedação Consciente/normas , Recuperação de Oócitos/efeitos adversos , Dor/prevenção & controle , Analgesia/efeitos adversos , Analgesia/métodos , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Anestesia/efeitos adversos , Anestesia/métodos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Feminino , Humanos , Recuperação de Oócitos/métodos , Dor/etiologia , Guias de Prática Clínica como Assunto , Resultado do Tratamento
15.
Semin Pediatr Surg ; 28(1): 33-42, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30824132

RESUMO

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.


Assuntos
Analgesia/métodos , Sedação Consciente/métodos , Cuidados Críticos/métodos , Sedação Profunda/métodos , Delírio , Assistência Perioperatória/métodos , Analgesia/efeitos adversos , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia/psicologia , Ansiolíticos/uso terapêutico , Ansiedade/tratamento farmacológico , Ansiedade/etiologia , Criança , Sedação Consciente/efeitos adversos , Sedação Consciente/psicologia , Cuidados Críticos/psicologia , Estado Terminal , Sedação Profunda/efeitos adversos , Sedação Profunda/psicologia , Delírio/diagnóstico , Delírio/etiologia , Delírio/prevenção & controle , Delírio/psicologia , Humanos , Pediatria , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/psicologia
16.
Cochrane Database Syst Rev ; 1: CD012819, 2019 01 16.
Artigo em Inglês | MEDLINE | ID: mdl-30650189

RESUMO

BACKGROUND: Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Therefore, it is critical to quantify the real benefits of epidural analgesia over other modes of pain treatment. OBJECTIVES: To assess the effectiveness and safety of epidural analgesia compared with systemic analgesia for acute postoperative pain control after thoraco-lumbar spine surgery in children. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature on 14 November 2018, together with the references lists of related reviews and retained trials, and two trials registers. SELECTION CRITERIA: We included all randomized controlled trials performed in children undergoing any type of thoraco-lumbar spine surgery comparing epidural analgesia with systemic analgesia for postoperative pain. We applied no language or publication status restriction. DATA COLLECTION AND ANALYSIS: We assessed risk of bias of included trials using the Cochrane tool. We analysed data using random-effects models. We rated the quality of the evidence according to the GRADE scale. MAIN RESULTS: We included 11 trials (559 participants) in the review, and seven trials (249 participants) in the analysis: 140 participants received epidural analgesia and 109 received systemic analgesia.Most studies included adolescents. Three trials included in the analysis contained some participants older than 18 years. The types of surgery were posterior spinal fusion for idiopathic scoliosis (nine trials), anterior correction for idiopathic scoliosis (one trial), or selective dorsal rhizotomy in children with cerebral palsy (one trial). The mean numbers of vertebrae operated on were between nine and 14.5 and the mean numbers of spinal levels were between three and four and a half. The length of surgery varied between three and six and a half hours.Compared with systemic analgesia, epidural analgesia reduced pain at rest at all time points. At six to eight hours, the mean pain score on a 0 to 10 scale with systemic analgesia was 3.1 (standard deviation 0.7) and with epidural analgesia was -1.32 points (95% confidence interval (CI) -1.83 to -0.82; 4 studies, 116 participants; moderate-quality evidence). At 72 hours, the mean pain score with epidural analgesia was equivalent to a -0.8 point reduction on a 0 to 10 scale (standardized mean difference (SMD) -0.65, 95% CI -1.19 to -0.10; 5 studies, 157 participants; moderate-quality evidence).Return of gastrointestinal functionThere was no difference for nausea and vomiting between groups (risk ratio (RR) 0.87, 95% CI 0.58 to 1.30; 6 studies, 215 participants; low-quality evidence). One study found epidural analgesia with local anaesthetics may have increased the number of participants who had their first flatus within 48 hours (RR 1.63, 95% CI 1.08 to 2.47; 30 participants; very low-quality evidence). Two studies found epidural analgesia with local anaesthetics may have increased the number of participants in whom first bowel movement occurred within 48 hours (RR 11.52, 95% CI 2.36 to 56.26; 60 participants; low-quality evidence). It was uncertain whether epidural analgesia reduced the time to first bowel movement (MD 0.09 days, 95% CI -0.32 to 0.50; 1 study, 60 participants; very low-quality evidence) and time to first liquid ingestion following epidural infusion of an opioid alone or a local anaesthetic plus an opioid (mean difference (MD) -5.02 hours, 95% CI -13.15 to 3.10; 2 studies, 56 participants; very low-quality evidence). Epidural analgesia with local anaesthetics may have increased the risk of having first solid food ingestion within 48 hours (RR 7.00, 95% CI 1.91 to 25.62; 1 study, 30 participants; very low-quality evidence).Secondary outcomesIt was uncertain whether there was a difference in time to ambulate (MD 0.08 days, 95% CI -0.24 to 0.39; 1 study, 60 participants; very low-quality evidence) and hospital length of stay (MD -0.29 days, 95% CI -0.69 to 0.10; 2 studies, 89 participants; very low-quality evidence). Two studies found participants were more satisfied when treated with epidural analgesia (MD 1.62 on a scale from 0 to 10, 95% CI 1.26 to 1.97; 60 participants; very low-quality evidence). It was unclear whether there was a difference in parent satisfaction for epidural analgesia with an opioid alone (MD 0.60, 95% CI -0.81 to 2.01; 1 trial, 27 participants; very low-quality evidence).ComplicationsIt was uncertain whether there was a difference in the risk of complications such as: respiratory depression (risk difference (RD) -0.05, 95% CI -0.16 to 0.05; 4 studies, 126 participants; very low-quality evidence); wound infection (RD 0.01, 95% CI -0.05 to 0.08; 2 trials, 93 participants; very low-quality evidence); epidural abscess (RD 0, 95% CI -0.05 to 0.05; 3 trials, 120 participants; very low-quality evidence); and neurological complications (RD 0.01, 95% CI -0.04 to 0.06; 4 studies, 151 participants; very low-quality evidence). AUTHORS' CONCLUSIONS: There is moderate- and low-quality evidence that there may be a small additional reduction in pain up to 72 hours after surgery with epidural analgesia compared with systemic analgesia. Two very small studies showed epidural analgesia with local anaesthetic alone may accelerate the return of gastrointestinal function. The safety of this technique in children undergoing thoraco-lumbar surgery is uncertain due to the very low-quality of the evidence. The study in 'Studies awaiting classification' may alter the conclusions of the review once assessed.


Assuntos
Analgesia Epidural , Analgesia/métodos , Vértebras Lombares/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Vértebras Torácicas/cirurgia , Analgesia/efeitos adversos , Analgesia Epidural/efeitos adversos , Deambulação Precoce/estatística & dados numéricos , Humanos , Duração da Cirurgia , Medição da Dor , Satisfação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Vômito/induzido quimicamente
17.
J Anesth ; 33(2): 238-249, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30617546

RESUMO

PURPOSE: Procedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan. METHODS: We formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA. RESULTS: We enrolled 332 patients in four EDs during the 12-month period. The median age was 67 years (IQR, 46-78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17-26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE. CONCLUSION: In a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries.


Assuntos
Analgesia/métodos , Sedação Consciente/métodos , Serviço Hospitalar de Emergência , Hipnóticos e Sedativos/administração & dosagem , Idoso , Analgesia/efeitos adversos , Anestesia/métodos , Cardioversão Elétrica/estatística & dados numéricos , Feminino , Humanos , Japão , Masculino , Midazolam/uso terapêutico , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Propofol/uso terapêutico , Tiopental/administração & dosagem
18.
Pediatr Emerg Care ; 35(2): 89-95, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28121974

RESUMO

OBJECTIVES: Children presenting with acute traumatic pain or in need of therapeutic or diagnostic procedures require rapid and effective analgesia and/or sedation. Intranasal administration (INA) promises to be a reliable, minimally invasive delivery route. However, INA is still underused in Germany. We hence developed a protocol for acute pain therapy (APT) and urgent analgesia and/or sedation (UAS). Our aim was to evaluate the effectiveness and safety of our protocol. METHODS: We performed a prospective observational study in a tertiary children's hospital in Germany. Pediatric patients aged 0 to 17 years requiring APT or UAS were included. Fentanyl, s-ketamine, midazolam, or combinations were delivered according to protocol. Primary outcome variables included quality of analgesia and/or sedation as measured on age-appropriate scales and time to onset of drug action. Secondary outcomes were adverse events and serious adverse events. RESULTS: One hundred pediatric patients aged 0.3 to 16 years were enrolled, 34 for APT and 66 for UAS. The median time onset of drug action was 5 minutes (ranging from 2 to 15 minutes). Fentanyl was most frequently used for APT (n = 19). Pain scores decreased by a median of 4 points (range, 0-10; P < 0.0001). For UAS, s-ketamine/midazolam was most frequently used (n = 25). Sedation score indicated minimal sedation in most cases. Overall success rate after the first attempt was 82%. Adverse events consisted of nasal burning (n = 2) and vomiting (n = 2). No serious adverse events were recorded. CONCLUSIONS: A fentanyl-, s-ketamine-, and midazolam-based INA protocol was effective and safe for APT and UAS. It should then be considered where intravenous access is impossible or inappropriate.


Assuntos
Dor Aguda/tratamento farmacológico , Administração Intranasal/métodos , Analgesia/métodos , Sedação Consciente/métodos , Manejo da Dor/métodos , Administração Intranasal/efeitos adversos , Adolescente , Analgesia/efeitos adversos , Criança , Pré-Escolar , Sedação Consciente/efeitos adversos , Serviço Hospitalar de Emergência , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Alemanha , Hospitais Pediátricos , Humanos , Lactente , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Masculino , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Medição da Dor/métodos , Estudos Prospectivos , Centros de Atenção Terciária , Resultado do Tratamento
19.
Korean J Anesthesiol ; 72(2): 135-142, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-29969888

RESUMO

BACKGROUND: Cholesterol plays an important role in the action of opioid analgesics, but its association with postoperative pain has not been clarified. Our study examined the association of pre- and postoperative total serum cholesterol (TSC), and change between the pre- and postoperative TSC levels with postoperative pain outcomes in patients with non-small cell lung cancer (NSCLC) who underwent video-assisted thoracoscopic surgery (VATS) lobectomy. METHODS: We retrospectively reviewed medical records of patients with NSCLC who underwent VATS lobectomy at the Seoul National University Bundang Hospital in South Korea. We sought to determine the association between preoperative TSC, TSC on postoperative day (POD) 0-1, and pre- and postoperative changes in TSC by comparing numeric rating scale (NRS) scores on POD 0, 1, and 2 and total morphine equivalent consumption on POD 0-2. Multivariate linear regression analyses were used, and P < 0.05 was considered statistically significant. RESULTS: A total of 1,720 patients with NSCLC who underwent VATS lobectomy were included in the analysis. The change in TSC, preoperative TSC, and postoperative TSC showed no associations with morphine equivalent consumption on POD 0-2 (P > 0.05). In addition, the changes in TSC, preoperative TSC, and postoperative TSC were not associated with postoperative NRS pain score on POD 0, 1, and 2 (P > 0.05). CONCLUSIONS: Our results indicated that no significant association was observed between pre- and postoperative TSC level and postoperative pain outcome after VATS lobectomy of the lung.


Assuntos
Analgesia/tendências , Analgésicos Opioides/administração & dosagem , Colesterol/sangue , Assistência Perioperatória/tendências , Cirurgia Torácica Vídeoassistida/tendências , Idoso , Analgesia/efeitos adversos , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida/efeitos adversos
20.
Curr Opin Anaesthesiol ; 32(1): 39-43, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30540577

RESUMO

PURPOSE OF REVIEW: The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. RECENT FINDINGS: VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors. CONCLUSION: The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients' tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience.


Assuntos
Analgesia/métodos , Anestesia/métodos , Anestésicos/efeitos adversos , Dor Pós-Operatória/terapia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Manuseio das Vias Aéreas/economia , Manuseio das Vias Aéreas/métodos , Analgesia/efeitos adversos , Analgesia/economia , Anestesia/efeitos adversos , Anestesia/economia , Anestésicos/administração & dosagem , Tomada de Decisão Clínica , Custos Hospitalares , Humanos , Tempo de Internação/economia , Monitorização Intraoperatória/economia , Monitorização Intraoperatória/métodos , Dor Pós-Operatória/etiologia , Período Pós-Operatório , Cirurgia Torácica Vídeoassistida/métodos , Fatores de Tempo
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