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1.
Rev Med Suisse ; 16(686): 553-556, 2020 Mar 18.
Artigo em Francês | MEDLINE | ID: mdl-32186802

RESUMO

Since 2018, a new analgesic drug has been made available in Switzerland : methoxyflurane. This halogenated gas, controlled by the patient, offers a very effective analgesic effect comparable to opiates. Known since the 1960s and used mainly in pre-hospital emergency medicine in Australia and New Zealand, its use in Europe is increasing alongside standard analgesic treatments in the traumatic setting. Administered by inhalation, it does not require an intravenous access, which is ideal in prehospital emergency situations. This treatment could be used for the management of acute pain of various origins, such as renal lithiasis, or to facilitate different procedures, such as closed fracture reduction or chest tube insertion. Its indications are growing and its use will probably become commonplace with clinicians in a near future.


Assuntos
Dor Aguda/tratamento farmacológico , Anestésicos Inalatórios/uso terapêutico , Metoxiflurano/administração & dosagem , Metoxiflurano/uso terapêutico , Manejo da Dor , Anestésicos Inalatórios/administração & dosagem , Humanos , Suíça
2.
Anaesthesia ; 75 Suppl 1: e101-e110, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31903582

RESUMO

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.


Assuntos
Dor Aguda/tratamento farmacológico , Anestesia por Condução/métodos , Manejo da Dor/métodos , Humanos
3.
Postgrad Med ; 132(1): 37-43, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31549932

RESUMO

Objective: Our institution implemented six multimodal, sliding scale protocols for managing pain in non-surgical inpatients. The purpose of this study was to compare the use of these acute pain protocols with traditional prescribing in regard to pain management efficacy and safety measures.Methods: This retrospective cohort study evaluated hospital in-patients who were prescribed one of the protocols during the first 6 months following implementation, admitted to the hospitalist service, and had received at least two doses of PRN analgesic medication within a 24-hour period. Data collected included baseline demographics, verbal pain rating scores to determine time to achieve analgesia, total opioid use in oral morphine equivalent doses (MEDs), and safety measures. A sample of patients admitted during the same time frame, meeting inclusion/exclusion criteria, but who received traditional analgesic prescribing served as controls.Results: Forty-six adult, non-surgical patients were included in the analysis, and 46 served as controls. The average baseline pain scores were similar between groups (7.26 in protocol, 7.43 in control, p = 0.684). Protocol patients required significantly less time to achieve meaningful analgesia (average 507.52 min) compared to the control group (894.33 min, p = 0.045). Patients in the protocol group used an average of 35.81 MEDs per day compared to 65.77 MEDs in controls (p = 0.019). Patients in the protocol group used significantly fewer PRN analgesic doses (12.70 vs. 24.02, p < 0.0001).Conclusion: Analysis of the implementation of acute pain management protocols indicates that using standardized pain management protocols of opioids, non-opioids, and medications to prevent opioid-related adverse events is more effective than traditional analgesic prescribing for our patient population.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/uso terapêutico , Prescrições de Medicamentos , Medição da Dor/métodos , Analgésicos Opioides/uso terapêutico , Protocolos Clínicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
4.
Acta Clin Croat ; 58(Suppl 1): 53-61, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31741560

RESUMO

The objective of this clinical update, based on recently published literature, was to discuss incidence and characteristics of the most relevant clinical adverse effects associated with local anesthetic and steroid use in regional anesthesia and treatment of acute or chronic pain. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from 2015 to 2018 was performed. This narrative review provides anesthesia practitioners with updated evidences on complications and contraindications of local anesthetic and steroid use with emphasis on current points of view regarding prevention, early diagnosis and treatment of adverse events.


Assuntos
Dor Aguda/tratamento farmacológico , Corticosteroides/efeitos adversos , Anestésicos Locais/efeitos adversos , Dor Crônica/tratamento farmacológico , Contraindicações de Medicamentos , Anestesia por Condução/efeitos adversos , Anestesia Local/efeitos adversos , Humanos , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos
5.
Presse Med ; 48(10): e273-e283, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31734048

RESUMO

OBJECTIVES: Self-medication for alleviating pain is very prevalent in most countries. While safe self-medication is supposed to be dependent on both patient's behaviour and pharmacist's counselling, little is known about the context of the delivery of analgesics available without prescription. The primary objective of the study was to define sociodemographic profiles and behaviours of patients seeking non-prescribed analgesics in French community pharmacies. Secondary objectives included the assessment of pharmacist management and identification of risk-associated patients. METHODS: This is a cross-sectional, national and multicentre study, including adults who asked for a prescription-free medication for acute or chronic physical pain. Information was collected through separate patient and healthcare professional (HCP) questionnaires. RESULTS: The analysis was based on 1215 and 1271 patient and HCP questionnaires, respectively, collected from 164 pharmacies. The patient population consisted in women and men (ratio 6:4), mainly (71%) under 60 years old. Headaches, rheumatologic and musculoskeletal pains were the most frequent reasons for getting analgesics, with a median pain intensity of 6 on a scale graded from 0 (no pain) to 10 (intolerable pain). The main reasons guiding self-medication were time saving, a well-known pain and a well-known product. The mean time allocated to delivery was 4.7minutes. Indications, dose and posology were almost systematically addressed by the pharmacy staff, while contra-indications, drug-drug interaction or safety were mentioned in around two-third of cases. The proportion of patients identified at risks due to an inappropriate context of self-medication was 15.5%. DISCUSSION AND CONCLUSIONS: This study shows a great heterogeneity of the population asking for non-prescribed analgesics in French community pharmacies. While pharmacists were able to identify patients at risks, a significant part may have 'slipped through the net'. The results support further studies to better define patient care pathway and optimize pharmacist-led medication.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/uso terapêutico , Dor Crônica/tratamento farmacológico , Medicamentos sem Prescrição/uso terapêutico , Farmacêuticos , Automedicação , Adulto , Fatores Etários , Idoso , Estudos Transversais , Feminino , França , Pesquisas sobre Serviços de Saúde , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Farmácias/estatística & dados numéricos , Tamanho da Amostra , Fatores Sexuais , Fatores Socioeconômicos
6.
J Opioid Manag ; 15(4): 275-283, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637680

RESUMO

OBJECTIVE: Inform readers of the use of a clinical pathway that includes initiation of methadone in hospitalized patients with acute pain who have untreated opioid use disorder (OUD). DESIGN: A retrospective chart review with frequency distributions and descriptive statistics calculated to describe demo-graphic and clinical characteristics of the sample. SETTING: Urban academic hospital. PATIENTS: One hundred twenty consecutive patients with untreated OUD cared for by the Acute Pain Service (APS). INTERVENTIONS: APS leadership spearheaded development of a clinical pathway to standardize pain management and optimize outcomes. The authors outline pathway development and describe 120 patients managed using this pathway, initiated on methadone for OUD. RESULTS: The sample included patients, average age 40 years, predominantly non-Hispanic white (74.2 percent), male (61.7 percent), unemployed (88.2 percent), and on Medicaid (84.2 percent). 96.7 percent had a history of heroin use, and 52.1 percent had engaged in previous medication-assisted treatment (MAT). Methadone or other opioids were held for signs of intoxication/sedation in 10.9 percent or for prolonged corrected QT interval in 1.7 percent. The majority received at least one other analgesic agent. For those prescribed opioids upon discharge, the average maximum morphine equivalent dose was 68.2 mg/day for approximately 3 days. 68.3 percent agreed to schedule post-discharge MAT, and of these, 68 percent attended their intake appointment. A small percentage (4.7 percent) left the hospital against medical advice. CONCLUSION: This pathway provides an example of an effective and safe response to address the opioid epidemic and pro-vide quality care to patients with OUD and pain.


Assuntos
Dor Aguda , Analgésicos Opioides/uso terapêutico , Metadona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides , Dor Aguda/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Clínicas de Dor , Estudos Retrospectivos
7.
Medicine (Baltimore) ; 98(42): e17621, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626143

RESUMO

While the pain after gynecological laparoscopy is assumed to be minor, many women suffer from unexpected postoperative pain in the post-anesthesia care unit (PACU). Prior identification of these patients is significant for effective analgesia. Therefore, we sought to determine the predictors for acute postoperative pain after gynecological laparoscopy. The data of 280 patients undergoing gynecological laparoscopy were analyzed. Data included demographic characteristics, previous obstetric/gynecologic surgical history, menstruation pattern including dysmenorrhea severity, gynecological hormone administration history, and surgical data (surgical time, endometriosis severity, adhesion, drainage insertion, and surgery type). Univariate analysis and binary logistic regression were used to evaluate predictors for substantial pain in the PACU after gynecologic laparoscopy. Among the 280 patients, 115 (41%) suffered from substantial postoperative pain in the PACU. Whenever the level of dysmenorrhea became more severe (none → mild → moderate → severe), the risk of substantial pain in the PACU increased 2.9-fold (odds ratio [OR] 2.92, 95% confidence interval [CI] 2.11-4.03, P < .001). Moreover, patients undergoing laparoscopy for ectopic pregnancy had a higher risk of substantial pain compared with the others (OR 3.11, 95% CI 1.36-7.12, P = .007). Other factors did not show a significant association with substantial pain. Patients with preoperative severe dysmenorrhea and those undergoing laparoscopy for ectopic pregnancy should be considered to have a high risk of substantial postoperative pain in the PACU so that they receive prompt and aggressive analgesic intervention. In particular, dysmenorrhea severity is clinically valuable as a useful predictor for substantial pain after gynecological laparoscopy.


Assuntos
Dor Aguda/diagnóstico , Analgésicos/uso terapêutico , Doenças dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Laparoscopia/efeitos adversos , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Dor Aguda/tratamento farmacológico , Dor Aguda/etiologia , Adulto , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos
8.
Am J Health Syst Pharm ; 76(19): 1511-1520, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31504147

RESUMO

PURPOSE: Current literature and clinical practice guidelines on pediatric pain management are reviewed. SUMMARY: Acute pain is commonly present in neonatal and pediatric patients due to underlying disease states or procedures. Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients. Despite the knowledge of pain being an important aspect in the management of children, barriers exist, leading to suboptimal treatment. Addressing these barriers through education of healthcare practitioners, families, and patients will lead to optimizing the patient pain experience. Tools for pain assessment vary depending on the type of pain, the child's age and understanding of pain, and the clinical situation. Pharmacotherapy options for pain management in neonates and pediatric patients include opioid and nonopioid agents. Efficacy and safety data on the use of medications for the treatment of pain in pediatric patients is described. The delivery of medication encompasses patient-specific factors and preferences. Strategies for opioid stewardship and management of iatrogenic withdrawal pose a unique challenge in pediatric patients. CONCLUSION: The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients. Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/farmacologia , Conduta do Tratamento Medicamentoso/normas , Manejo da Dor/normas , Medição da Dor/normas , Dor Aguda/diagnóstico , Fatores Etários , Analgésicos/uso terapêutico , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Humanos , Recém-Nascido , Manejo da Dor/métodos , Medição da Dor/métodos , Educação de Pacientes como Assunto , Guias de Prática Clínica como Assunto
10.
J Headache Pain ; 20(1): 81, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31307383

RESUMO

BACKGROUND: OnabotulinumtoxinA (BOTOX®, Allergan plc, Dublin, Ireland) is approved for the preventive treatment of headaches in adult patients with chronic migraine (CM) in Australia by the country's reimbursement mechanism for medicines, the Pharmaceutical Benefits Scheme (PBS). To our knowledge, this study represents the first focused report evaluating real-world evidence of onabotulinumtoxinA treatment via the PBS in Australian clinics. METHODS: This study reviewed the medical records of adults with inadequately controlled CM from 7 private neurology practices in Australia who, beginning in March 2014, received PBS-subsidized onabotulinumtoxinA per product labelling for the first time. The primary effectiveness measure was the percentage of patients achieving a response defined by 50% or greater reduction in headache days from baseline after 2 treatment cycles. Additional data were recorded in the case report form when available and included demographics, clinical characteristics, headache severity and frequency, Headache Impact Test (HIT-6) score, medication use, and days missed of work or study at baseline, after 2 treatment cycles, and at last follow-up. Differences in mean changes from baseline were evaluated with a 1-tailed t-test or Pearson's chi-squared test (p < 0.05). RESULTS: The study population included 211 patients with a mean (SD) of 25.2 (5.3) monthly headache days at baseline. In the primary outcome analysis, 74% of patients achieved a response, with a mean (SD) of 10.6 (7.9) headache days after 2 treatment cycles (p < 0.001). Secondary effectiveness outcomes included mean (SD) reductions in HIT-6 score of - 11.7 (9.8) and - 11.8 (12.2) after 2 treatment cycles (p < 0.001) and final follow-up (p < 0.001), respectively, and mean (SD) decreases in days per month of acute pain medication use of - 11.5 (7.6) after 2 treatment cycles (p < 0.001) and - 12.7 (8.1) at final follow-up (p < 0.001). CONCLUSION: This study provides additional clinical evidence for the consistent effectiveness of onabotulinumtoxinA for the treatment of CM in Australia. This effectiveness was made evident by reductions in migraine days, severe headache days, and HIT-6 scores from baseline.


Assuntos
Toxinas Botulínicas Tipo A/uso terapêutico , Cefaleia/tratamento farmacológico , Cefaleia/prevenção & controle , Transtornos de Enxaqueca/prevenção & controle , Dor Aguda/tratamento farmacológico , Dor Aguda/prevenção & controle , Adulto , Austrália/epidemiologia , Doença Crônica , Feminino , Cefaleia/epidemiologia , Humanos , Masculino , Registros Médicos , Pessoa de Meia-Idade , Transtornos de Enxaqueca/tratamento farmacológico , Transtornos de Enxaqueca/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Resultado do Tratamento
11.
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 , 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
12.
Chirurg ; 90(8): 652-659, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31359112

RESUMO

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.


Assuntos
Dor Aguda , Anestesiologia , Anti-Inflamatórios não Esteroides , Dipirona , Dor Aguda/tratamento farmacológico , Analgésicos , Anti-Inflamatórios não Esteroides/uso terapêutico , Cuidados Críticos , Dipirona/uso terapêutico , Humanos
13.
Schmerz ; 33(4): 287-294, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31342162

RESUMO

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.


Assuntos
Agranulocitose , Dipirona , Dor Aguda/tratamento farmacológico , Dor Aguda/prevenção & controle , Agranulocitose/induzido quimicamente , Agranulocitose/prevenção & controle , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Anestesiologia/normas , Associação , Cuidados Críticos , Dipirona/administração & dosagem , Dipirona/efeitos adversos , Humanos , Período Perioperatório
14.
Anesthesiol Clin ; 37(3): 507-520, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31337481

RESUMO

The management of acute pain in older adults (age 65 or greater) requires special attention due to various physiologic, cognitive, functional, and social issues that may change with aging. Especially in the postoperative setting, there are significant complications that can occur if pain is not treated adequately for elderly patients. In this article, the authors describe these changes in detail and discuss how pain should be assessed appropriately in older patients. In addition, the authors detail the unique risks and benefits of several mainstream analgesic medications as well as interventional treatments for elderly patients. The authors' goal is to provide recommendations for health care providers on appropriately recognizing and treating pain in a safe, effective manner for aging patients.


Assuntos
Dor Aguda/tratamento farmacológico , Manejo da Dor/métodos , Dor Aguda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Analgésicos/administração & dosagem , Analgésicos/uso terapêutico , Anestesia por Condução , Humanos
15.
Emerg Med J ; 36(8): 506-508, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31358553

RESUMO

A short-cut review of the literature was carried out to establish whether inhaled methoxyflurane (Penthrox) is comparable or superior with a standard inhalational analgesia for the management of acute pain. Only two papers were identified as suitable for inclusion using the reported search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. It is concluded that both methods of inhaled analgesia appear to be useful options for acute pain in the ED when compared with placebo. No evidence was found to suggest superiority of methoxypenflurane. International studies directly comparing the use of both drugs for in acute trauma are ongoing and will develop the evidence base.


Assuntos
Metoxiflurano/normas , Óxido Nitroso/normas , Oxigênio/normas , Manejo da Dor/normas , Dor Aguda/tratamento farmacológico , Analgésicos/normas , Analgésicos/uso terapêutico , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Metoxiflurano/uso terapêutico , Óxido Nitroso/uso terapêutico , Oxigênio/uso terapêutico , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos
16.
Br J Anaesth ; 123(3): 335-349, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31303268

RESUMO

Systemic administration of the local anaesthetic lidocaine is antinociceptive in both acute and chronic pain states, especially in acute postoperative and chronic neuropathic pain. These effects cannot be explained by its voltage-gated sodium channel blocking properties alone, but the responsible mechanisms are still elusive. This narrative review focuses on available experimental evidence of the molecular mechanisms by which systemic lidocaine exerts its clinically documented analgesic effects. These include effects on the peripheral nervous system and CNS, where lidocaine acts via silencing ectopic discharges, suppression of inflammatory processes, and modulation of inhibitory and excitatory neurotransmission. We highlight promising objectives for future research to further unravel these antinociceptive mechanisms, which subsequently may facilitate the development of new analgesic strategies and therapies for acute and chronic pain.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/farmacologia , Anestésicos Locais/farmacologia , Dor Crônica/tratamento farmacológico , Lidocaína/farmacologia , Terapia de Alvo Molecular/métodos , Dor Aguda/metabolismo , Analgésicos/uso terapêutico , Anestésicos Locais/uso terapêutico , Anti-Inflamatórios não Esteroides/farmacologia , Anti-Inflamatórios não Esteroides/uso terapêutico , Dor Crônica/metabolismo , Humanos , Canais Iônicos/efeitos dos fármacos , Lidocaína/uso terapêutico , Transmissão Sináptica/efeitos dos fármacos
17.
PLoS Med ; 16(7): e1002849, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31310600

RESUMO

BACKGROUND: Intravenous morphine (IVM) is the most common strong analgesic used in trauma, but is associated with a clear time limitation related to the need to obtain an access route. The intranasal (IN) route provides easy administration with a fast peak action time due to high vascularization and the absence of first-pass metabolism. We aimed to determine whether IN sufentanil (INS) for patients presenting to an emergency department with acute severe traumatic pain results in a reduction in pain intensity non-inferior to IVM. METHODS AND FINDINGS: In a prospective, randomized, multicenter non-inferiority trial conducted in the emergency departments of 6 hospitals across France, patients were randomized 1:1 to INS titration (0.3 µg/kg and additional doses of 0.15 µg/kg at 10 minutes and 20 minutes if numerical pain rating scale [NRS] > 3) and intravenous placebo, or to IVM (0.1 mg/kg and additional doses of 0.05 mg/kg at 10 minutes and 20 minutes if NRS > 3) and IN placebo. Patients, clinical staff, and research staff were blinded to the treatment allocation. The primary endpoint was the total decrease on NRS at 30 minutes after first administration. The prespecified non-inferiority margin was -1.3 on the NRS. The primary outcome was analyzed per protocol. Adverse events were prospectively recorded during 4 hours. Among the 194 patients enrolled in the emergency department cohort between November 4, 2013, and April 10, 2016, 157 were randomized, and the protocol was correctly administered in 136 (69 IVM group, 67 INS group, per protocol population, 76% men, median age 40 [IQR 29 to 54] years). The mean difference between NRS at first administration and NRS at 30 minutes was -4.1 (97.5% CI -4.6 to -3.6) in the IVM group and -5.2 (97.5% CI -5.7 to -4.6) in the INS group. Non-inferiority was demonstrated (p < 0.001 with 1-sided mean-equivalence t test), as the lower 97.5% confidence interval of 0.29 (97.5% CI 0.29 to 1.93) was above the prespecified margin of -1.3. INS was superior to IVM (intention to treat analysis: p = 0.034), but without a clinically significant difference in mean NRS between groups. Six severe adverse events were observed in the INS group and 2 in the IVM group (number needed to harm: 17), including an apparent imbalance for hypoxemia (3 in the INS group versus 1 in the IVM group) and for bradypnea (2 in the INS group versus 0 in the IVM group). The main limitation of the study was that the choice of concomitant analgesics, when they were used, was left to the discretion of the physician in charge, and co-analgesia was more often used in the IVM group. Moreover, the size of the study did not allow us to conclude with certainty about the safety of INS in emergency settings. CONCLUSIONS: We confirm the non-inferiority of INS compared to IVM for pain reduction at 30 minutes after administration in patients with severe traumatic pain presenting to an emergency department. The IN route, with no need to obtain a venous route, may allow early and effective analgesia in emergency settings and in difficult situations. Confirmation of the safety profile of INS will require further larger studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT02095366. EudraCT 2013-001665-16.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Morfina/administração & dosagem , Manejo da Dor/métodos , Sufentanil/administração & dosagem , Ferimentos e Lesões/diagnóstico , Dor Aguda/diagnóstico , Dor Aguda/etiologia , Administração Intranasal , Administração Intravenosa , Adulto , Aerossóis , Analgésicos Opioides/efeitos adversos , Método Duplo-Cego , Serviço Hospitalar de Emergência , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/efeitos adversos , Manejo da Dor/efeitos adversos , Estudos Prospectivos , Índice de Gravidade de Doença , Sufentanil/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Ferimentos e Lesões/complicações
18.
Emerg Med J ; 36(7): 401-406, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31217178

RESUMO

OBJECTIVE: The current study aimed to ascertain differences in early postmedication pain reduction in participants presenting with acute musculoskeletal injuries (MSI) to the ED receiving intramuscular (IM) versus per oral (PO) diclofenac. METHODS: This was a prospective, double-blinded, randomised controlled trial conducted between January and June 2018 at the ED of Hamad General Hospital in Doha, Qatar. Adults (18-65 years of age) presenting to the ED within 24 hours of an acute MSI, who had a triage pain score measured using numerical rating scale of at least five or above were enrolled in this trial. Participants randomised to either IM (75 mg) with oral placebo, or oral (100 mg) diclofenac group with IM placebo using a computer-generated randomised concealed list in blocks of six and eight. The primary objective was to compare the proportion of IM versus PO participants attaining a 50% reduction in pain score at 30 min from t0. RESULTS: 300 participants were enrolled (150 in the IM diclofenac group and 150 in the PO diclofenac group) in the trial. The primary outcome was achieved in 99.3 (95% CI 96.3 to 100) in the IM group and 86.7 (95% CI 80.2 to 91.7) in PO group. There was an absolute risk difference of 12.7%. This corresponds to a number needed to treat of 8 cases (95% CI 6 to 14) receiving IM rather than the PO diclofenac in order to achieve one additional case of 50% pain reduction within 30 min of drug administration. There were no adverse events experienced in any treatment groups. CONCLUSION: IM diclofenac injection provides rapid analgesia over PO administration of diclofenac. However, given the preparation needed for an IM injection, oral administration may be preferable when and if clinical circumstances allow a choice in non-steroidal anti-inflammatory drug administration route.


Assuntos
Administração Oral , Diclofenaco/administração & dosagem , Injeções Intramusculares/métodos , Doenças Musculoesqueléticas/tratamento farmacológico , Dor Aguda/tratamento farmacológico , Adolescente , Adulto , Idoso , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/farmacologia , Anti-Inflamatórios não Esteroides/uso terapêutico , Diclofenaco/farmacologia , Diclofenaco/uso terapêutico , Método Duplo-Cego , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/epidemiologia , Estudos Prospectivos , Catar/epidemiologia
19.
Surgery ; 166(3): 375-379, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31196705

RESUMO

BACKGROUND: In response to the growing opioid crisis, Florida recently implemented a law restricting the duration of opioid prescriptions for acute pain. Little is known about the impact of such legislation on opioid prescription practices at the time of discharge after surgery. The objective of this study was to determine whether Florida's new legislation changed opioid prescription practices for analgesia after surgery. METHODS: Adults 18 years of age and older undergoing cholecystectomy, appendectomy, hernia repair, hysterectomy, mastectomy, or lymph node dissection were included in this retrospective cohort study at a large public university-affiliated hospital. We analyzed opioid prescriptions on discharge after these common outpatient surgical procedures between June 1, 2017, and December 31, 2018. Florida House Bill 21 was passed on March 2, 2018, and subsequent implementation of this law took place on July 1, 2018. The law restricts the duration of opioid prescriptions for acute pain to 3 days, which can be extended up to a maximum of 7 days with additional documentation. The outcomes studied included the following: the proportion of patients receiving opioid prescriptions on discharge, total opioid dose prescribed, daily opioid dose prescribed, and the proportion of patients receiving more than a 3-day supply of opioids. We colledted data on emergency department cumulative visits within 7 and 30 days after discharge. Drug doses were converted to morphine milligram equivalents and calculated for each selected procedure. RESULTS: A total of 1,467 surgical encounters were included. The cohort was predominantly female (963 [65.6%]) with a mean (SD) age of 49.6 (14.4) years. At 6 months after implementation of HB 21, the proportion of patients receiving opioid prescriptions decreased by 21% (95% CI 16.8% to 25.3%, P < .001), mean total opioid dose prescribed decreased by 64.2 morphine milligram equivalents (95% CI 54.7 to 73.7, P < .001) from a baseline mean (SD) of 172.5 (78.9) morphine milligram equivalents. The mean daily opioid dose prescribed increased by 3.5 morphine milligram equivalents (95% CI 1.8 to 5.1, P < .001) from a baseline mean (SD) of 30.5 (9.4) morphine milligram equivalents. The proportion of patients receiving opioid prescriptions for longer than a 3-day supply decreased by 68% (95% CI 63.4% to 72.7%, P < .001). We observed no change in the number of postoperative emergency department visits before and after implementation of the law. CONCLUSION: Opioid prescriptions for patients undergoing common outpatient surgical procedures at a large public university-affiliated hospital in Florida were substantially reduced within 6 months after implementation of state legislation limiting the duration of opioid prescriptions. This reduction was not associated with an increase in the number of postoperative emergency department visits. The legislation should significantly decrease the amount of unused opioid pills potentially available for diversion and abuse. Secondary effects from the enactment of this law remain to be evaluated.


Assuntos
Dor Aguda/epidemiologia , Dor Aguda/etiologia , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides , Prescrições de Medicamentos , Manejo da Dor , Dor Pós-Operatória/epidemiologia , Centros Médicos Acadêmicos , Dor Aguda/tratamento farmacológico , Adulto , Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos Opioides/administração & dosagem , Estudos de Coortes , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Florida/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Manejo da Dor/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico
20.
BMJ ; 365: l1849, 2019 May 14.
Artigo em Inglês | MEDLINE | ID: mdl-31088782

RESUMO

OBJECTIVE: To determine the risk of prolonged opioid use in patients receiving tramadol compared with other short acting opioids. DESIGN: Observational study of administrative claims data. SETTING: United States commercial and Medicare Advantage insurance claims (OptumLabs Data Warehouse) January 1, 2009 through June 30, 2018. PARTICIPANTS: Opioid-naive patients undergoing elective surgery. MAIN OUTCOME MEASURE: Risk of persistent opioid use after discharge for patients treated with tramadol alone compared with other short acting opioids, using three commonly used definitions of prolonged opioid use from the literature: additional opioid use (defined as at least one opioid fill 90-180 days after surgery); persistent opioid use (any span of opioid use starting in the 180 days after surgery and lasting ≥90 days); and CONSORT definition (an opioid use episode starting in the 180 days after surgery that spans ≥90 days and includes either ≥10 opioid fills or ≥120 days' supply of opioids). RESULTS: Of 444 764 patients who met the inclusion criteria, 357 884 filled a discharge prescription for one or more opioids associated with one of 20 included operations. The most commonly prescribed post-surgery opioid was hydrocodone (53.0% of those filling a single opioid), followed by short acting oxycodone (37.5%) and tramadol (4.0%). The unadjusted risk of prolonged opioid use after surgery was 7.1% (n=31 431) with additional opioid use, 1.0% (n=4457) with persistent opioid use, and 0.5% (n=2027) meeting the CONSORT definition. Receipt of tramadol alone was associated with a 6% increase in the risk of additional opioid use relative to people receiving other short acting opioids (incidence rate ratio 95% confidence interval 1.00 to 1.13; risk difference 0.5 percentage points; P=0.049), 47% increase in the adjusted risk of persistent opioid use (1.25 to 1.69; 0.5 percentage points; P<0.001), and 41% increase in the adjusted risk of a CONSORT chronic opioid use episode (1.08 to 1.75; 0.2 percentage points; P=0.013). CONCLUSIONS: People receiving tramadol alone after surgery had similar to somewhat higher risks of prolonged opioid use compared with those receiving other short acting opioids. Federal governing bodies should consider reclassifying tramadol, and providers should use as much caution when prescribing tramadol in the setting of acute pain as for other short acting opioids.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Transtornos Relacionados ao Uso de Opioides , Dor Pós-Operatória/tratamento farmacológico , Tramadol/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Humanos , Alta do Paciente , Estudos Retrospectivos , Fatores de Risco
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