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1.
Ann Emerg Med ; 77(3): 345-356, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33358232

RESUMO

STUDY OBJECTIVE: We compare the efficacy and adverse effects of 5 oral analgesics in emergency department (ED) patients aged 21 to 64 years with acute musculoskeletal pain. METHODS: This was a randomized clinical trial conducted in 2 urban EDs. Patients received 400 mg ibuprofen/1,000 mg acetaminophen, 800 mg ibuprofen/1,000 mg acetaminophen, 30 mg codeine/300 mg acetaminophen, 5 mg hydrocodone/300 mg acetaminophen, or 5 mg oxycodone/325 mg acetaminophen. The primary outcome was change in pain before administration of medication (baseline) to 1 hour postbaseline. A numeric rating scale was used, varying from 0="no pain" to 10="worst imaginable pain." Secondary outcomes included receipt of rescue medication and adverse effects at 1 and 2 hours postbaseline. ANOVA was used to test differences in the primary outcome between treatment groups. RESULTS: Six hundred participants, predominantly men and Latino, were enrolled. Change in pain from baseline to 60 minutes did not differ by treatment (P=.69). The mean change in pain in numeric rating scale units was 400 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% confidence interval [CI] 2.6 to 3.5); 800 mg ibuprofen/1,000 mg acetaminophen 3.0 (95% CI 2.5 to 3.5), 30 mg codeine/300 mg acetaminophen 3.4 (95% CI 2.9 to 3.9), 5 mg hydrocodone/300 mg acetaminophen 3.1 (95% CI 2.7 to 3.5), and 5 mg oxycodone/325 mg acetaminophen 3.3 (95% CI 2.8 to 3.7). Rescue medication was received before 1 hour had elapsed by 2 patients receiving 400 mg ibuprofen/1,000 mg acetaminophen (1.7%), 3 patients receiving 800 mg ibuprofen/1,000 mg acetaminophen (2.5%), zero patients receiving 30 mg codeine/300 mg acetaminophen (0.0%), 3 patients receiving 5 mg hydrocodone/300 mg acetaminophen (2.5%), and zero patients receiving 5 mg oxycodone/325 mg acetaminophen (0.0%) (P=.21). More patients who received opioids were nauseated or vomited compared with those who did not: 6.7% versus 1.7% (5.0% difference; 95% CI 1.7% to 8.2%). The findings at 2 hours were similar. CONCLUSION: No analgesic was more efficacious than others 1 or 2 hours after baseline. There was significantly more nausea and vomiting among patients treated with opioids.


Assuntos
Dor Aguda/tratamento farmacológico , Serviço Hospitalar de Emergência , Dor Musculoesquelética/tratamento farmacológico , Dor Aguda/diagnóstico , Administração Oral , Adulto , Analgésicos , Método Duplo-Cego , Extremidades , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Musculoesquelética/diagnóstico , Medição da Dor , Resultado do Tratamento
2.
Ann Intern Med ; 173(12): JC65, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33316185

RESUMO

SOURCE CITATION: Busse JW, Sadeghirad B, Oparin Y, et al. Management of acute pain from non-low back, musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials. Ann Intern Med. 2020;173:730-8. 32805127.


Assuntos
Acetaminofen , Dor Aguda , Acetaminofen/uso terapêutico , Dor Aguda/tratamento farmacológico , Anti-Inflamatórios não Esteroides/efeitos adversos , Humanos , Metanálise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto
3.
Ann. intern. med ; 173(9): 739-748, Nov. 3, 2020. tab.
Artigo em Inglês | BIGG - guias GRADE | ID: biblio-1146639

RESUMO

The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non­low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP.


Assuntos
Humanos , Adulto , Dor nas Costas/terapia , Dor Aguda/terapia , Sistema Musculoesquelético/lesões , Dor nas Costas/etiologia , Dor nas Costas/tratamento farmacológico , Dor Aguda/etiologia , Dor Aguda/tratamento farmacológico
4.
Ann Emerg Med ; 76(3S): S12-S20, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32928457

RESUMO

STUDY OBJECTIVE: This was a prospective, pre-post, 13-year observational study documenting the multiyear implementation of an observation unit sickle cell pathway for patients with uncomplicated vaso-occlusive events. METHODS: The sickle cell pathway begins with rapid triage to identify patients with uncomplicated vaso-occlusive events for immediate transfer to the observation unit and initiation of patient-controlled analgesia followed by repeated evaluations of pain and identification of other complications. Data were abstracted from the electronic medical record or observation unit database. The sickle cell pathway was initiated in April 2006. Major revisions of it were carried out in June 2009 (physician evaluation occurs in sickle cell pathway and only patient-controlled analgesia administration of medications) and October 2010 (multidisciplinary management and individual dosing). RESULTS: Annual ED visits ranged between 287 and 528. The preimplementation hospital admission rate was 33% (123/368), 3-day return rate 16% (60/368), and 30-day return rate 67% (248/368). Refinements to the sickle cell pathway have resulted in a decrease in admission rate to 20% (258/1276); 3-day return rate, to 3.6% (46/1,276); and 30-day return rate, to 41% (525/1,276) for the past 3 years. CONCLUSION: The use of a sickle cell pathway for the treatment of uncomplicated vaso-occlusive events has been effective in providing rapid treatment and reducing hospital admissions. However, it was not only the intervention and its refinement that made the sickle cell pathway successful. With the Consolidated Framework for Implementation Research, it was discerned that outer setting factors of organizational commitment to the care of patients with SCD, inner setting factors of learning climate and leadership engagement, individuals, and process contributed to the success of the sickle cell pathway.


Assuntos
Analgesia Controlada pelo Paciente/métodos , Anemia Falciforme/terapia , Unidades de Observação Clínica , Serviço Hospitalar de Emergência , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Adolescente , Adulto , Idoso , Anemia Falciforme/complicações , Estudos Controlados Antes e Depois , Procedimentos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos Prospectivos , Triagem , Doenças Vasculares/etiologia , Adulto Jovem
5.
Ann Emerg Med ; 76(3S): S6-S11, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32928464

RESUMO

STUDY OBJECTIVE: The National Heart, Lung, and Blood Institute evidence-based guidelines for timeliness of opioid administration for sickle cell disease (SCD) pain crises recommend an initial opioid within 1 hour of arrival, with subsequent dosing every 30 minutes until pain is controlled. No multisite studies have evaluated guideline adherence, to our knowledge. Our objective was to determine guideline adherence across a multicenter network. METHODS: We conducted a multiyear cross-sectional analysis of children with SCD who presented between January 1, 2016, and December 31, 2018, to 7 emergency departments (EDs) within the Pediatric Emergency Care Applied Research Network. Visits for uncomplicated pain crisis were included, defined with an International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 code for SCD crisis and receipt of an opioid, excluding visits with other SCD complications or temperature exceeding 38.5°C (101.3°F). Times were extracted from the electronic record. Guideline adherence was assessed across sites and calendar years. RESULTS: A total of 4,578 visits were included. The median time to first opioid receipt was 62 minutes (interquartile range 42 to 93 minutes); between the first and second opioid receipt, 60 minutes (interquartile range 39 to 93 minutes). Overall, 48% of visits (95% confidence interval 47% to 50%) were guideline adherent for first opioid. Of 3,538 visits with a second opioid, 15% (95% confidence interval 14% to 16%) were guideline adherent. Site variation in adherence existed for time to first opioid (range 22% to 70%) and time between first and second opioid (range 2% to 36%; both P<.001). There was no change in timeliness to first dose or time between doses across years (P>.05 for both). CONCLUSION: Guideline adherence for timeliness of SCD treatment is poor, with half of visits adherent for time to first opioid and one seventh adherent for second dose. Dissemination and implementation research/quality improvement efforts are critical to improve care across EDs.


Assuntos
Analgésicos Opioides/uso terapêutico , Anemia Falciforme/terapia , Fidelidade a Diretrizes/estatística & dados numéricos , Manejo da Dor/métodos , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Adolescente , Analgésicos Opioides/administração & dosagem , Anemia Falciforme/complicações , Estudos Transversais , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Manejo da Dor/normas , Sistema de Registros , Fatores de Tempo , Estados Unidos
6.
J Opioid Manag ; 16(4): 297-306, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32885838

RESUMO

Tramadol is a centrally acting dual-mechanism (opioid and monoamine reuptake inhibition) analgesic that has been noted to have a lower risk of abuse compared to conventional opioids such as morphine. Oral tramadol has been ap-proved in the United States since 1995 and intravenous (IV) tramadol has been widely prescribed outside the United States (OUS); nevertheless, IV tramadol has not yet been approved for use in the United States. This paper provides a review of the pharmacokinetics (PK) of the IV tramadol dosing regimen being developed in the United States, its abuse potential as documented in the literature, and its safety record in clinical practice, and discusses how IV tramadol may become a useful option for patients in the United States with acute pain.


Assuntos
Dor Aguda , Analgésicos Opioides , Transtornos Relacionados ao Uso de Opioides , Tramadol , Dor Aguda/tratamento farmacológico , Administração Intravenosa , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/farmacocinética , Humanos , Morfina , Tramadol/efeitos adversos , Tramadol/farmacocinética
7.
Sports Health ; 12(6): 540-546, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936058

RESUMO

CONTEXT: With increased use of cannabis-based products by the public for both recreational and medical use, sports medicine clinicians should be informed of historical context, current legal considerations, and existing evidence with regard to efficacy, safety, and risks in the athletic community. EVIDENCE ACQUISITION: A review of ClinicalTrials.gov, MEDLINE, and CINAHL from 2015 to present was conducted with emphasis on the most recent literature using search terms, cannabis, nabiximols, cannabinoids, pain management, THC, CBD, and marijuana. Bibliographies based on original search were utilized to pursue further literature search. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: At present, limited high-quality studies exist for use of cannabinoids for acute pain, chronic pain, or concussion. None of the trials involving cannabinoids included the athletic population. Thus, results from this clinical review are extrapolated to conditions of the sports medicine population. For acute pain, 2 small-randomized double-blinded crossover trials concluded no immediate effect of cannabinoid therapy. More robust evidence exists for treatment of chronic pain conditions through meta-analysis and systemic reviews. Cannabinoid therapy exhibits moderate efficacy as a treatment for some chronic pain conditions. Investigations included a broad spectrum of chronic pain conditions, including neuropathic, musculoskeletal, inflammatory, and central pain conditions, and reveal reduction in pain and improvement of quality of life with limited adverse effects. For concussion, evidence is based on preclinical in vitro and animal models revealing possible neuroprotective effects as well as 2 clinical studies involving the presence of cannabinoids for concussion (some sports-related), but there are no high-quality trials evaluating efficacy for treatment with cannabinoids at this time. CONCLUSION: Although various biochemical explanations exist on the use of cannabinoid therapy through modulation of the endocannabinoid system for several medical issues affecting athletes, recommendations from clinicians must be extrapolated from a majority of research done in the nonathletic population. Lack of strong-quality clinical evidence, coupled with inconsistent federal and state law as well as purity issues with cannabis-based products, make it difficult for the sports medicine clinician to widely recommend cannabinoid therapeutics at present. Future larger, higher quality clinical research studies with standardized pure extracts will better guide appropriate medical use going forward. At present, evidence for a multitude of therapeutic applications is emerging for cannabinoid treatment approaches. With emphasis placed on patient-centered clinical decisions, cannabinoids hold promise of treatment for athletes with chronic pain conditions. Clinicians who treat the athletic community must consider legal and ethical issues when discussing and recommending the use of cannabinoids, with acknowledgment of inconsistencies in purity of various formulations and concerns of drug testing.


Assuntos
Traumatismos em Atletas/complicações , Canabinoides/uso terapêutico , Maconha Medicinal/uso terapêutico , Manejo da Dor/métodos , Dor Aguda/tratamento farmacológico , Traumatismos em Atletas/tratamento farmacológico , Concussão Encefálica/tratamento farmacológico , Canabinoides/efeitos adversos , Dor Crônica/tratamento farmacológico , Medicina Baseada em Evidências/normas , Humanos , Uso da Maconha/legislação & jurisprudência , Maconha Medicinal/efeitos adversos , Estados Unidos
8.
Am J Emerg Med ; 38(9): 1767-1771, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32739846

RESUMO

BACKGROUND: This study aimed to compare the analgesic efficacy of topical capsaicin and topical piroxicam in acute musculoskeletal injuries. METHODS: This is a prospective, randomized, controlled, double-blinded study. The data for the 67 patients in the piroxicam group and the 69 in the capsaicin group were examined. The initial visual analog scale (VAS) scores were compared with the 60th and 120th minute as well as the 24th and 72nd hour values. Differences between the VAS scores, clinical effectiveness of the treatment and side effects were evaluated. RESULTS: In the capsaicin group, the mean difference in the delta VAS scores was significantly higher at each measurement time. The mean of the percentage of reduction in the VAS scores of the topical capsaicin group was significantly higher than that in the topical piroxicam group. The highest difference in terms of both outcomes was determined at the 72nd hour VAS change. Mean differences were 1.53 (95% CI: 0.85-2.221) and 19.7 (95% CI: 12.4-27.2) respectively (p < 0.001). In the capsaicin group, the clinical effect of the treatment was found significantly higher (p < 0.01). The difference between the clinical effectiveness of the groups regarding the treatment outcomes was also statistically significant (p < 0.001). There was no significant difference between the patient groups regarding the presence of side effects. CONCLUSION: Topical capsaicin can be used as an alternative to topical piroxicam initially and at follow-up in patients presenting to the emergency department with acute pain as there were no observable differences in side-effects between the two groups.


Assuntos
Dor Aguda/tratamento farmacológico , Capsaicina/administração & dosagem , Inibidores de Ciclo-Oxigenase/administração & dosagem , Piroxicam/administração & dosagem , Fármacos do Sistema Sensorial/administração & dosagem , Administração Tópica , Adolescente , Adulto , Idoso , Método Duplo-Cego , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos
9.
Am J Emerg Med ; 38(9): 1860-1866, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32739857

RESUMO

STUDY OBJECTIVE: To assess the efficacy and safety of intranasal analgesic-dose ketamine as compared to intranasal fentanyl for pediatric acute pain. METHODS: A systematic review and meta-analysis was performed following the PRISMA guidelines. We searched PubMed, Embase, and Scopus databases for randomized controlled trials from inception to December 2019. We conducted meta-analysis with random-effects models to evaluate pain reduction, rescue analgesia, adverse events and sedation between intranasal ketamine and intranasal fentanyl. Random-effects models were used to estimate weighted mean differences (WMD) and pooled relative risks (RR). RESULTS: A total of 546 studies were screened and 4 trials were included. In the meta-analysis of 4 studies including 276 patients, ketamine had similar reductions in pain scores from baseline to all post-intervention times (10 to 15 min: WMD -1.42, 95% CI -9.95 to 7.10; 30 min: WMD 0.40, 95% CI -6.29 to 7.10; 60 min: WMD -0.64, 95% CI -6.76 to 5.47). Ketamine was associated with similar rates of rescue analgesia (RR 0.74, 95% CI 0.44 to 1.25). Ketamine had a higher risk of non-serious adverse events (RR 2.00, 95% CI 1.43 to 2.79), and no patients receiving ketamine had a serious adverse event. There was one serious adverse event (hypotension) with fentanyl that self-resolved. No patients receiving either IN fentanyl or ketamine had significant sedation. CONCLUSION: Intranasal analgesic-dose ketamine may be considered as an alternative to opioids for acute pain management in children. Its accepted use will depend on the tolerability of non-serious adverse events and the desire to avoid opioids.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/uso terapêutico , Ketamina/uso terapêutico , Manejo da Dor/métodos , Administração Intranasal , Analgésicos/administração & dosagem , Criança , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Humanos , Ketamina/administração & dosagem
10.
Am Surg ; 86(8): 926-932, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32749863

RESUMO

BACKGROUND: Rib fractures are common injuries among traumatically injured patients, and elderly patients with rib fractures are at increased risk for adverse events and death. The purpose of this study was to determine if oral Per os (PO) acetaminophen is as effective as intravenous (IV) acetaminophen in treating the pain associated with rib fractures. METHODS: We performed a single-center, randomized, placebo-controlled, double-blinded study. Trauma patients who were ≥65 years old and had ≥1 rib fracture were included in this study. Patients were randomized into IV acetaminophen and oral placebo (n = 63) or IV placebo and oral solution acetaminophen (n = 75) groups. The primary outcome was a mean reduction in pain score at 24 hours, and secondary outcomes included opioid use, intensive care unit (ICU) length of stay (LOS), hospital LOS, hospital mortality, the difference in incentive spirometry, and development of pneumonia. RESULTS: Among the 138 patients included, there was no statistically significant difference between the 2 study groups in a mean reduction in pain score at 24 hours after injury (PO: 3.24, IV: 2.49; P = .230). Opioid pain medication use was equivalent between groups (P = .212), and there was no significant difference in hospital mortality rate between groups (P = .827). There was no statistically significant difference in ICU LOS, hospital LOS, or development of pneumonia. DISCUSSION: In elderly trauma patients (age ≥65 years) with 1 or more rib fractures, PO acetaminophen is equivalent to IV acetaminophen for pain control, with no difference in morbidity or mortality. Oral acetaminophen should be preferentially used over IV acetaminophen when treating the elderly trauma patient with rib fractures.


Assuntos
Acetaminofen/administração & dosagem , Dor Aguda/tratamento farmacológico , Analgésicos não Entorpecentes/administração & dosagem , Dor Musculoesquelética/tratamento farmacológico , Fraturas das Costelas/complicações , Acetaminofen/uso terapêutico , Dor Aguda/etiologia , Administração Intravenosa , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Analgésicos não Entorpecentes/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Masculino , Dor Musculoesquelética/etiologia , Estudos Prospectivos , Resultado do Tratamento
11.
Rev. Soc. Esp. Dolor ; 27(4): 257-268, jul.-ago. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-196842

RESUMO

Los pacientes con enfermedad de células falciformes (ECF), también denominada drepanocítica, sufren un dolor intenso que suele comenzar durante la infancia y aumenta su gravedad a lo largo de la vida, lo que lleva a la hospitalización y a una mala calidad de vida a lo largo de los años. Una característica única de la ECF son las crisis vaso-oclusivas (CVO), caracterizadas por episodios recurrentes e impredecibles de dolor agudo. La obstrucción microvascular durante una CVO provoca una disminución del suministro de oxígeno a la periferia y una lesión por isquemia y posterior reperfusión, inflamación, estrés oxidativo y disfunción endotelial, todo lo cual puede perpetuar un microambiente nocivo que provoca dolor. Por otro lado, además de los dolores agudos episódicos, los pacientes con ECF también padecen dolor crónico, definido como dolor casi diario durante un periodo de 6 meses, asociado a trastornos psicosociales. Pueden deberse a lesiones crónicas como úlceras cutáneas, necrosis avascular ósea o infartos en diversos órganos. Asimismo, la sensibilización central parece estar directamente involucrada en la cronicidad del dolor y existe un componente de dolor neuropático claramente infradiagnosticado e infratratado. El tratamiento actual del dolor moderado a intenso en la ECF se basa principalmente en la administración de los opioides, vía oral, de liberación rápida ambulatoria o en forma de analgesia controlada por el paciente vía intravenosa intrahospitalaria. Sin embargo, el uso de opioides a largo plazo está asociado con múltiples efectos secundarios. Esta revisión presenta los últimos avances en la comprensión de la fisiopatología del dolor en la ECF y se describen los mecanismos subyacentes que pueden ayudar a desarrollar nuevas estrategias terapéuticas y/o preventivas para mejorar el dolor en la ECF


Patients with sickle cell disease (SCD) suffer from severe pain that often begins in childhood and increases in severity over the course of a lifetime, leading to hospitalization and poor quality of life over the years. A unique feature of SCD is vase-occlusive crises (VOC) characterized by recurrent and unpredictable episodes of acute pain. Microvascular occlusion during a VOC results in decreased oxygen supply to the periphery and injury from ischemia and subsequent reperfusion, inflammation, oxidative stress and endothelial dysfunction, all of which can perpetuate a harmful pain-causing microenvironment. On the other hand, in addition to episodic acute pain, SCD patients also report chronic pain, defined as almost daily pain over a 6-month period associated to either sicologic or social morbidities. They may be due to chronic lesions such as skin ulcers, avascular bone necrosis or infarctions in various organs. In addition, central sensitization appears to be directly involved in the chronicity of pain and there is a clearly under-diagnosed and under-treated component of neuropathic pain. Current treatment of moderate to severe pain in SCD is based primarily on opioids; either as an oral quick release outpatient or in the form of patient-controlled intravenous analgesia in the hospital. However, long-term opioid use is associated with multiple side effects. This review presents the latest advances in the understanding of the pathology of pain in SCD and describes objectives based on mechanisms that may help to develop new therapeutic and/or preventive strategies to improve pain in SCD


Assuntos
Humanos , Anemia Falciforme/fisiopatologia , Dor Aguda/fisiopatologia , Dor Crônica/fisiopatologia , Analgésicos Opioides/uso terapêutico , Dor Aguda/tratamento farmacológico , Dor Crônica/tratamento farmacológico , Analgesia/métodos , Manejo da Dor/métodos
12.
Rev. Soc. Esp. Dolor ; 27(4): 269-272, jul.-ago. 2020. ilus
Artigo em Espanhol | IBECS | ID: ibc-196843

RESUMO

Las fracturas costales tienen una elevada prevalencia en nuestra sociedad. Un adecuado y precoz control analgésico resulta fundamental a la hora de evitar complicaciones respiratorias y favorecer una rápida recuperación funcional en los pacientes con fracturas costales. Se han empleado diferentes estrategias para dicho control analgésico, desde fármacos intravenosos hasta técnicas regionales más clásicas como el catéter epidural o el bloqueo paravertebral torácico. El bloqueo ecoguiado del plano profundo del músculo erector de la espina (ESPB) constituye una alternativa eficaz en el manejo del dolor agudo derivado de las fracturas costales, permitiendo una fisioterapia y rehabilitación precoz


Rib fractures have a high prevalence in our society. An adequate and precocious analgesic control is essential to avoid respiratory complications and favor a rapid functional recovery in patients with rib fractures. Different strategies have been used for analgesic control, from intravenous drugs to more classic regional techniques such as epidural catheter or thoracic paravertebral block. Ultrasound-guided blockade of the deep plane of the erector spine muscle (ESPB) is an effective alternative in the management of acute pain derived from rib fractures, allowing physiotherapy and early rehabilitation


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo/complicações , Dor Aguda/tratamento farmacológico , Fraturas das Costelas/tratamento farmacológico , Analgésicos/administração & dosagem , Analgesia Controlada pelo Paciente/métodos , Bloqueio Nervoso/métodos , Infusão Espinal/métodos , Resultado do Tratamento , Medição da Dor/métodos , Cateteres de Demora , Cateterismo/métodos
13.
Cochrane Database Syst Rev ; 7: CD012129, 2020 07 24.
Artigo em Inglês | MEDLINE | ID: mdl-32702783

RESUMO

BACKGROUND: Perineal trauma, due to spontaneous tears, surgical incision (episiotomy), or in association with operative vaginal birth, is common after vaginal birth, and is often associated with postpartum perineal pain. Birth over an intact perineum may also lead to perineal pain. There are adverse health consequences associated with perineal pain for the women and their babies in the short- and long-term, and the pain may interfere with newborn care and the establishment of breastfeeding. Aspirin has been used in the management of postpartum perineal pain, and its effectiveness and safety should be assessed. This is an update of the review, last published in 2017. OBJECTIVES: To determine the effects of a single dose of aspirin (acetylsalicylic acid), including at different doses, in the relief of acute postpartum perineal pain. SEARCH METHODS: For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register (4 October 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (4 October 2019) and screened reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs), assessing single dose aspirin compared with placebo, no treatment, a different dose of aspirin, or single dose paracetamol or acetaminophen, for women with perineal pain in the early postpartum period. We planned to include cluster-RCTs, but none were identified. We excluded quasi-RCTs and cross-over studies. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included RCTs. Data were checked for accuracy. The certainty of the evidence for the main comparison (aspirin versus placebo) was assessed using the GRADE approach. MAIN RESULTS: We included 17 RCTs, 16 of which randomised 1132 women to aspirin or placebo; one RCT did not report numbers of women. Two RCTs (of 16) did not contribute data to meta-analyses. All women had perineal pain post-episiotomy, and were not breastfeeding. Studies were published between 1967 and 1997, and the risk of bias was often unclear, due to poor reporting. We included four comparisons: aspirin versus placebo (15 RCTs); 300 mg versus 600 mg aspirin (1 RCT); 600 mg versus 1200 mg aspirin (2 RCTs); and 300 mg versus 1200 mg aspirin (1 RCT). Aspirin versus placebo Aspirin may result in more women reporting adequate pain relief four to eight hours after administration compared with placebo (risk ratio (RR) 2.03, 95% confidence interval (CI) 1.69 to 2.42; 13 RCTs, 1001 women; low-certainty evidence). It is uncertain whether aspirin compared with placebo has an effect on the need for additional pain relief (RR 0.25, 95% CI 0.17 to 0.37; 10 RCTs, 744 women; very low-certainty evidence), or maternal adverse effects (RR 1.08, 95% CI 0.57 to 2.06; 14 RCTs, 1067 women; very low-certainty evidence), four to eight hours after administration. Analyses based on dose did not reveal any clear subgroup differences. 300 mg versus 600 mg aspirin It is uncertain whether over four hours after administration, 300 mg compared with 600 mg aspirin has an effect on adequate pain relief (RR 0.82, 95% CI 0.36 to 1.86; 1 RCT, 81 women) or the need for additional pain relief (RR 0.68, 95% CI 0.12 to 3.88; 1 RCT, 81 women). There were no maternal adverse effects in either aspirin group. 600 mg versus 1200 mg aspirin It is uncertain whether over four to eight hours after administration, 600 mg compared with 1200 mg aspirin has an effect on adequate pain relief (RR 0.85, 95% CI 0.52 to 1.39; 2 RCTs, 121 women), the need for additional pain relief (RR 1.32, 95% CI 0.30 to 5.68; 2 RCTs, 121 women), or maternal adverse effects (RR 3.00, 95% CI 0.13 to 69.52; 2 RCTs, 121 women). 300 mg versus 1200 mg aspirin It is uncertain whether over four hours after administration, 300 mg compared with 1200 mg aspirin has an effect on adequate pain relief (RR 0.62, 95% CI 0.29 to 1.32; 1 RCT, 80 women) or need for additional pain relief (RR 2.00, 95% CI 0.19 to 21.18; 1 RCT, 80 women). There were no maternal adverse effects in either aspirin group. None of the included RCTs reported on neonatal adverse effects. No RCTs reported on secondary review outcomes of: prolonged hospitalisation due to perineal pain; re-hospitalisation due to perineal pain; fully breastfeeding at discharge; mixed feeding at discharge; fully breastfeeding at six weeks; mixed feeding at six weeks; perineal pain at six weeks; maternal views; or maternal postpartum depression. AUTHORS' CONCLUSIONS: Single dose aspirin may increase adequate pain relief in women with perineal pain post-episiotomy compared with placebo. It is uncertain whether aspirin has an effect on the need for additional analgesia, or on maternal adverse effects, compared with placebo. We downgraded the certainty of the evidence because of study limitations (risk of bias), imprecision, and publication bias. Aspirin may be considered for use in non-breastfeeding women with post-episiotomy perineal pain. Included RCTs excluded breastfeeding women, so there was no evidence to assess the effects of aspirin on neonatal adverse effects or breastfeeding. Future RCTs should be designed to ensure low risk of bias, and address gaps in the evidence, such as the secondary outcomes established for this review. Current research has focused on women with post-episiotomy pain; future RCTs could be extended to include women with perineal pain associated with spontaneous tears or operative birth.


Assuntos
Dor Aguda/tratamento farmacológico , Anti-Inflamatórios não Esteroides/administração & dosagem , Aspirina/administração & dosagem , Complicações do Trabalho de Parto/tratamento farmacológico , Períneo , Episiotomia/efeitos adversos , Feminino , Humanos , Dor Pós-Operatória/tratamento farmacológico , Efeito Placebo , Período Pós-Parto , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
14.
Clin Drug Investig ; 40(8): 755-764, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32583295

RESUMO

BACKGROUND AND OBJECTIVE: Opioid-induced respiratory depression (OIRD) is a potentially fatal complication associated with conventional opioids. Currently, there is a paucity of validated endpoints available to measure respiratory safety. Oliceridine, an investigational intravenous (IV) opioid, is a G-protein selective µ-agonist with limited activity on ß-arrestin2, a signaling pathway associated with adverse events including OIRD. In controlled phase III trials, oliceridine 0.35 mg and 0.5 mg demand doses demonstrated comparable analgesia to morphine 1 mg with favorable improvements in respiratory safety. In this exploratory analysis, we report dosing interruption (DI) and average cumulative duration of DI (CDDI) for both oliceridine and morphine. METHODS: Patients requiring analgesia after bunionectomy or abdominoplasty were randomized to IV demand doses of placebo, oliceridine (0.1 mg, 0.35 mg, or 0.5 mg), or morphine (1 mg), administered via patient-controlled analgesia (PCA), following a loading dose (oliceridine 1.5 mg, morphine 4 mg, volume-matched placebo) with a 6-min lockout interval. Certified nurse anesthetists monitored each patient and withheld study medication according to the patient's respiratory status. For each patient, the duration of all DIs was summed and reported as CDDI. A zero-inflated gamma mixture model was used to compute the mean CDDI for each treatment. RESULTS: Proportion of patients with DI was lower with oliceridine (0.1 mg: 3.2%, 0.35 mg: 13.9%, 0.5 mg: 15.1%) versus morphine (22%). The CDDI was also lower across all demand doses of oliceridine versus morphine. CONCLUSION: Using DI as a surrogate for OIRD indicates improved respiratory safety with oliceridine versus morphine that merits further investigation.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Morfina/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Insuficiência Respiratória/induzido quimicamente , Compostos de Espiro/efeitos adversos , Tiofenos/efeitos adversos , Adulto , Analgesia Controlada pelo Paciente , Analgésicos Opioides/administração & dosagem , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Manejo da Dor , Medição da Dor , Insuficiência Respiratória/tratamento farmacológico , Compostos de Espiro/administração & dosagem , Tiofenos/administração & dosagem
15.
Expert Opin Pharmacother ; 21(12): 1407-1418, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32486875

RESUMO

INTRODUCTION: Sufentanil is a selective µ-opioid agonist, used intravenously and intrathecally for moderate to severe acute pain. Sublingual sufentanil nanotablets have been developed; 15 mcg tablet for a patient-controlled analgesia device and 30-mcg tablet for a single-dose device administered by a healthcare professional. Dosing interval is a minimum of 20 min for a 15 mcg tablet and a treatment duration of up to 72 hours. The single 30-mcg nanotablet dosing interval is 1 hour. Mean plasma elimination half-life is 13 hours and bioavailability 47-57% after the first sublingual sufentanil tablet. AREAS COVERED: This review focuses on the effectiveness, safety, and feasibility of sublingual sufentanil 30-mcg single dose suspended by a healthcare professional for the management of moderate to severe acute pain. A few Phase 4 studies concerning the sublingual sufentanil tablet system containing 15-mcg nanotablets are also reviewed. EXPERT OPINION: Sufentanil sublingual 30-mcg nanotablets provide effective pain relief in various acute moderate to severe pain states. The safety profile of sublingual sufentanil 30 mcg is typical to opioids nausea, vomiting, and sedation being the most common ones. Sublingual sufentanil 30-mcg nanotablet has the potential for efficient moderate to severe pain management in supervised healthcare facilities.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Sistemas de Liberação de Medicamentos/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Sufentanil/administração & dosagem , Dor Aguda/sangue , Administração Sublingual , Analgesia Controlada pelo Paciente , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Disponibilidade Biológica , Duração da Terapia , Feminino , Humanos , Náusea/induzido quimicamente , Medição da Dor , Dor Pós-Operatória/sangue , Sufentanil/efeitos adversos , Sufentanil/uso terapêutico , Comprimidos
17.
Drugs Today (Barc) ; 56(4): 269-286, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32309822

RESUMO

Oliceridine is a next-generation investigational intravenous opioid that is a G protein-selective agonist at the µ-opioid receptor. The G protein selectivity of this compound results in potent analgesia with substantially reduced recruitment of ß-arrestin, a signaling pathway associated with opioid-related adverse events. In randomized, placebo- and active-controlled clinical studies, use of oliceridine for the management of moderate to severe acute pain provided potent analgesic effect superior to that observed with placebo, with lower incidence of adverse events, including respiratory events and gastrointestinal events of nausea and vomiting, compared with morphine. Here, we provide a review of the preclinical and clinical data of intravenous oliceridine, a selective agonist, which has the potential to offer a wider therapeutic window than conventional opioids.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Compostos de Espiro/uso terapêutico , Tiofenos/uso terapêutico , Proteínas de Ligação ao GTP/agonistas , Humanos , Morfina , Ensaios Clínicos Controlados Aleatórios como Assunto , Receptores Opioides mu
18.
PLoS One ; 15(4): e0231571, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32294125

RESUMO

BACKGROUND: Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management. METHODS: We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation's impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact). RESULTS: Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion. CONCLUSIONS: Our model highlighted the putative positive organizational impact of methoxyflurane in the ED-particularly when supported by a trauma care pathway-and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine.


Assuntos
Dor Aguda/tratamento farmacológico , Anestésicos Inalatórios/administração & dosagem , Técnicas de Apoio para a Decisão , Serviço Hospitalar de Emergência/organização & administração , Metoxiflurano/administração & dosagem , Terapias em Estudo/métodos , Ferimentos e Lesões/terapia , Dor Aguda/diagnóstico , Dor Aguda/etiologia , Tomada de Decisão Clínica/métodos , Procedimentos Clínicos , Aglomeração , Tratamento de Emergência/métodos , França , Humanos , Tempo de Internação , Modelos Organizacionais , Avaliação de Processos e Resultados em Cuidados de Saúde , Manejo da Dor/métodos , Medição da Dor , Projetos Piloto , Autoadministração , Fatores de Tempo , Ferimentos e Lesões/complicações
19.
Cochrane Database Syst Rev ; 4: CD013581, 2020 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-32297973

RESUMO

BACKGROUND: Acute low back pain (LBP) is a common health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used in the treatment of LBP, particularly in people with acute LBP. In 2008, a Cochrane Review was published about the efficacy of NSAIDs for LBP (acute, chronic, and sciatica), identifying a small but significant effect in favour of NSAIDs compared to placebo for short-term pain reduction and global improvement in participants with acute LBP. This is an update of the previous review, focusing on acute LBP. OBJECTIVES: To assess the effects of NSAIDs compared to placebo and other comparison treatments for acute LBP. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PubMed, and two trials registers for randomised controlled trials (RCT) to 7 January 2020. We also screened the reference lists from relevant reviews and included studies. SELECTION CRITERIA: We included RCTs that assessed the use of one or more types of NSAIDs compared to placebo (the main comparison) or alternative treatments for acute LBP in adults (≥ 18 years); conducted in both primary and secondary care settings. We assessed the effects of treatment on pain reduction, disability, global improvement, adverse events, and return to work. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials to be included in this review, evaluated the risk of bias, and extracted the data. If appropriate, we performed a meta-analysis, using a random-effects model throughout, due to expected variability between studies. We assessed the quality of the evidence using the GRADE approach. We used standard methodological procedures recommended by Cochrane. MAIN RESULTS: We included 32 trials, with a total of 5356 participants (age range 16 to 78 years). Follow-up ranged from one day to six months. Studies were conducted across the globe, the majority taking place in Europe and North-America. Africa and the Eastern Mediterranean region were not represented. We considered seven studies at low risk of bias. Performance and attrition were the most common biases. There was often a lack of information on randomisation procedures and allocation concealment (selection bias); studies were prone to selective reporting bias, since most studies did not register their trials. Almost half of the studies were industry-funded. There is moderate quality evidence that NSAIDs are slightly more effective in short-term (≤ 3 weeks) reduction of pain intensity (visual analogue scale (VAS), 0 to 100) than placebo (mean difference (MD) -7.29 (95% confidence interval (CI) -10.98 to -3.61; 4 RCTs, N = 815). There is high quality evidence that NSAIDs are slightly more effective for short-term improvement in disability (Roland Morris Disability Questionnaire (RMDQ), 0 to 24) than placebo (MD -2.02, 95% CI -2.89 to -1.15; 2 RCTs, N = 471). The magnitude of these effects is small and probably not clinically relevant. There is low quality evidence that NSAIDs are slightly more effective for short-term global improvement than placebo (risk ratio (RR) 1.40, 95% CI 1.12 to 1.75; 5 RCTs, N = 1201), but there was substantial heterogeneity (I² 52%) between studies. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events when using NSAIDs compared to placebo (RR 0.86, 95% CI 0.63 to 1.18; 6 RCTs, N = 1394). There is very low quality evidence of no clear difference between the proportion of participants who could return to work after seven days between those who used NSAIDs and those who used placebo (RR 1.48, 95% CI 0.98 to 2.23; 1 RCT, N = 266). There is low quality evidence of no clear difference in short-term reduction of pain intensity between those who took selective COX-2 inhibitor NSAIDs compared to non-selective NSAIDs (mean change from baseline -2.60, 95% CI -9.23 to 4.03; 2 RCTs, N = 437). There is moderate quality evidence of conflicting results for short-term disability improvement between groups (2 RCTs, N = 437). Low quality evidence from one trial (N = 333) reported no clear difference between groups in the proportion of participants experiencing global improvement. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events between those who took COX-2 inhibitors and non-selective NSAIDs (RR 0.97, 95% CI 0.63 to 1.50; 2 RCTs, N = 444). No data were reported for return to work. AUTHORS' CONCLUSIONS: This updated Cochrane Review included 32 trials to evaluate the efficacy of NSAIDs in people with acute LBP. The quality of the evidence ranged from high to very low, thus further research is (very) likely to have an important impact on our confidence in the estimates of effect, and may change the estimates. NSAIDs seemed slightly more effective than placebo for short-term pain reduction (moderate certainty), disability (high certainty), and global improvement (low certainty), but the magnitude of the effects is small and probably not clinically relevant. There was no clear difference in short-term pain reduction (low certainty) when comparing selective COX-2 inhibitors to non-selective NSAIDs. We found very low evidence of no clear difference in the proportion of participants experiencing adverse events in both the comparison of NSAIDs versus placebo and selective COX-2 inhibitors versus non-selective NSAIDs. We were unable to draw conclusions about adverse events and the safety of NSAIDs for longer-term use, since we only included RCTs with a primary focus on short-term use of NSAIDs and a short follow-up. These are not optimal for answering questions about longer-term or rare adverse events.


Assuntos
Dor Aguda/tratamento farmacológico , Anti-Inflamatórios não Esteroides/uso terapêutico , Dor Lombar/tratamento farmacológico , Adolescente , Adulto , Idoso , Anti-Inflamatórios não Esteroides/efeitos adversos , Inibidores de Ciclo-Oxigenase 2/efeitos adversos , Inibidores de Ciclo-Oxigenase 2/uso terapêutico , Avaliação da Deficiência , Humanos , Pessoa de Meia-Idade , Medição da Dor , Placebos/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
J Surg Res ; 252: 80-88, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32247074

RESUMO

BACKGROUND: The objective of this meta-analysis is to assess the analgesic effect of flurbiprofen on postoperative pain in Chinese surgical patients. METHODS: The primary outcome was acute postoperative pain scores; the secondary outcomes included total opiate consumption during surgery and adverse effects, such as nausea, vomiting, and dizziness. Results were expressed as weighted mean difference (WMD) or odds ratio with 95% confidence intervals (95% CIs). We evaluated heterogeneity by visually examining the forest plots and quantified it by using the I2 statistic. We used random-effects models to pool the data. RESULTS: Of 573 abstracts reviewed, 19 studies involving 1628 participants met the inclusion criteria. Pooled results showed that the intravenous administration of flurbiprofen had a beneficial effect in reducing pain scores at 2 (WMD, -0.78; 95% CI, -1.22 to -0.34; P = 0.001), 6 (WMD, -0.93; 95% CI, -1.40 to -0.46; P = 0.000), 12 (WMD, -1.09; 95% CI, -1.93 to -0.24; P = 0.011), 24 (WMD, -1.08; 95% CI, -1.48 to -0.68; P = 0.000), and 48 (WMD, -0.62; 95% CI, -1.19 to -0.05; P = 0.032) h after surgery. In addition, flurbiprofen administration significantly decreased the incidence of postoperative nausea and vomiting (odds ratio, 0.39; 95% CI, 0.26-0.58; P = 0.000) but had no effects on opiate consumption and dizziness. CONCLUSIONS: The perioperative administration of flurbiprofen is effective in reducing postoperative pain, nausea, and vomiting in Chinese surgical patients. Future studies with adequate power should evaluate the ideal flurbiprofen regimen for postoperative pain.


Assuntos
Dor Aguda/tratamento farmacológico , Anti-Inflamatórios não Esteroides/administração & dosagem , Flurbiprofeno/administração & dosagem , Dor Pós-Operatória/tratamento farmacológico , Náusea e Vômito Pós-Operatórios/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Dor Aguda/diagnóstico , Dor Aguda/etiologia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , China/epidemiologia , Flurbiprofeno/efeitos adversos , Humanos , Medição da Dor/estatística & dados numéricos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/métodos , Náusea e Vômito Pós-Operatórios/etiologia , Náusea e Vômito Pós-Operatórios/prevenção & controle , Resultado do Tratamento
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