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1.
Anesth Analg ; 132(4): 1138-1145, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33617181

RESUMO

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


Assuntos
Analgesia Epidural , Nefrectomia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Ohio , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
2.
Anesth Analg ; 132(4): 1129-1137, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33464760

RESUMO

BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.


Assuntos
Agonistas Adrenérgicos/administração & dosagem , Anestésicos Locais/administração & dosagem , Bloqueio do Plexo Braquial , Bupivacaína/administração & dosagem , Epinefrina/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Ropivacaina/administração & dosagem , Ultrassonografia de Intervenção , Agonistas Adrenérgicos/efeitos adversos , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Anestésicos Locais/efeitos adversos , Artroscopia/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Bupivacaína/efeitos adversos , Epinefrina/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora/efeitos dos fármacos , Ontário , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Ropivacaina/efeitos adversos , Articulação do Ombro/cirurgia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
3.
Anesthesiology ; 134(3): 421-434, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33449996

RESUMO

BACKGROUND: The primary goal of this study was to evaluate patterns in acute postoperative pain in a mixed surgical patient cohort with the hypothesis that there would be heterogeneity in these patterns. METHODS: This study included 360 patients from a mixed surgical cohort whose pain was measured across postoperative days 1 through 7. Pain was characterized using the Brief Pain Inventory. Primary analysis used group-based trajectory modeling to estimate trajectories/patterns of postoperative pain. Secondary analysis examined associations between sociodemographic, clinical, and behavioral patient factors and pain trajectories. RESULTS: Five distinct postoperative pain trajectories were identified. Many patients (167 of 360, 46%) were in the moderate-to-high pain group, followed by the moderate-to-low (88 of 360, 24%), high (58 of 360, 17%), low (25 of 360, 7%), and decreasing (21 of 360, 6%) pain groups. Lower age (odds ratio, 0.94; 95% CI, 0.91 to 0.99), female sex (odds ratio, 6.5; 95% CI, 1.49 to 15.6), higher anxiety (odds ratio, 1.08; 95% CI, 1.01 to 1.14), and more pain behaviors (odds ratio, 1.10; 95% CI, 1.02 to 1.18) were related to increased likelihood of being in the high pain trajectory in multivariable analysis. Preoperative and intraoperative opioids were not associated with postoperative pain trajectories. Pain trajectory group was, however, associated with postoperative opioid use (P < 0.001), with the high pain group (249.5 oral morphine milligram equivalents) requiring four times more opioids than the low pain group (60.0 oral morphine milligram equivalents). CONCLUSIONS: There are multiple distinct acute postoperative pain intensity trajectories, with 63% of patients reporting stable and sustained high or moderate-to-high pain over the first 7 days after surgery. These postoperative pain trajectories were predominantly defined by patient factors and not surgical factors.


Assuntos
Analgésicos Opioides/uso terapêutico , Morfina/uso terapêutico , Dor Pós-Operatória/fisiopatologia , Fatores Etários , Estudos de Coortes , Feminino , Florida , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Estudos Prospectivos , Índice de Gravidade de Doença , Fatores Sexuais
4.
Br J Anaesth ; 126(2): 445-457, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33461725

RESUMO

Electroencephalographic (EEG) activity is used to monitor the neurophysiology of the brain, which is a target organ of general anaesthesia. Besides its use in evaluating hypnotic states, neurophysiologic reactions to noxious stimulation can also be observed in the EEG. Recognising and understanding these responses could help optimise intraoperative analgesic management. This review describes three types of changes in the EEG induced by noxious stimulation when the patient is under general anaesthesia: (1) beta arousal, (2) (paradoxical) delta arousal, and (3) alpha dropout. Beta arousal is an increase in EEG power in the beta-frequency band (12-25 Hz) in response to noxious stimulation, especially at lower doses of anaesthesia drugs in the absence of opioids. It is usually indicative of a cortical depolarisation and increased cortical activity. At higher concentrations of anaesthetic drug, and with insufficient opioids, delta arousal (increased power in the delta band [0.5-4 Hz]) and alpha dropout (decreased alpha power [8-12 Hz]) are associated with noxious stimuli. The mechanisms of delta arousal are not well understood, but the midbrain reticular formation seems to play a role. Alpha dropout may indicate a return of thalamocortical communication, from an idling mode to an operational mode. Each of these EEG changes reflect an incomplete modulation of pain signals and can be mitigated by administration of opioid or the use of regional anaesthesia techniques. Future studies should evaluate whether titrating analgesic drugs in response to these EEG signals reduces postoperative pain and influences other postoperative outcomes, including the potential development of chronic pain.


Assuntos
Analgésicos/administração & dosagem , Anestesia Geral , Anestésicos Gerais/administração & dosagem , Ondas Encefálicas/efeitos dos fármacos , Encéfalo/efeitos dos fármacos , Eletroencefalografia , Monitorização Neurofisiológica Intraoperatória , Nociceptividade/efeitos dos fármacos , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/prevenção & controle , Encéfalo/fisiopatologia , Relação Dose-Resposta a Droga , Humanos , Dor Pós-Operatória/fisiopatologia , Estimulação Física , Valor Preditivo dos Testes , Fatores de Tempo , Resultado do Tratamento
5.
Sci Rep ; 10(1): 22321, 2020 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-33339895

RESUMO

The aim was to compare short-term results of transvaginal hybrid-NOTES (NSR) with traditional laparoscopic technique in sigmoid resection (LSR) in cases of diverticulitis. Natural Orifice Transluminal Endoscopic Surgery has been evolved as a minimally invasive procedure to reduce the operative trauma due to the absence of specimen extraction through the abdominal wall causing less postoperative pain, and shorter hospital stay. Despite the increasing use and published case series of NSR for diverticulitis as a laparoscopic procedure with transvaginal stapling and specimen extraction, there are no studies comparing this procedure with LSR. Twenty NSR patients operated at the Cologne-Merheim Medical Center have been documented and compared with 20 female LSR patients matched for body mass index, American Society of Anesthesiologists-classification (ASA), Hansen/Stock classification, and age. To ensure comparability regarding peri- and postoperative care, only procedures performed by the same surgeon were included. Procedural time, intra- and postoperative complications, conversion rate, postoperative pain, the duration of an epidural catheter, analgesic consumption, and postoperative length of hospital stay were analyzed. There were no significant differences in the sum of pain levels (p = 0.930), length of procedure (p = 0.079), intra- and postoperative complications, as well as duration of an epidural catheter. On the contrary, there were significant positive effects for NSR on morphine requirement at day seven and eight (p = 0.019 and p = 0.035 respectively) as well as the postoperative length of hospital stay (p = 0.031). This retrospective study reveals significant positive effects for NSR compared to LSR regarding length of hospital stay as well as morphine consumption after removal of the epidural catheter, whereas there were no significant differences in complication rate and procedural time. In summary, NSR is an adequate alternative to traditional laparoscopic sigmoid resection considering the surgeons experience and the patient's personal preferences.


Assuntos
Colo Sigmoide/cirurgia , Doenças do Colo/cirurgia , Diverticulite/cirurgia , Doenças Inflamatórias Intestinais/cirurgia , Colo Sigmoide/fisiopatologia , Doenças do Colo/complicações , Doenças do Colo/fisiopatologia , Diverticulite/complicações , Diverticulite/patologia , Feminino , Humanos , Doenças Inflamatórias Intestinais/complicações , Doenças Inflamatórias Intestinais/fisiopatologia , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cirurgia Endoscópica por Orifício Natural/métodos , Dor Pós-Operatória/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Vagina/anatomia & histologia , Vagina/cirurgia
6.
Ann Thorac Cardiovasc Surg ; 26(4): 196-201, 2020 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-32493872

RESUMO

OBJECTIVE: To evaluate the effect of music therapy on the chronic pain and midterm quality of life of patients after mechanical valve replacement. METHODS: Patients were divided into two groups according to whether or not they received music therapy. The patients in the music group received 30 minutes of music therapy every day for 6 months after the operation. The patients in the control group received standard treatment and had 30 minutes of quiet rest time every day in the same period. The short-form of McGill Pain Questionnaire (SF-MPQ) was used to evaluate the degree of postoperative chronic pain, and the SF-36 was used to evaluate the midterm quality of life of patients. RESULTS: In terms of the degree of postoperative chronic pain, the score of the pain rating index (PRI) emotional item in the music group was significantly lower than that in the control group. In the evaluation of the postoperative midterm quality of life using the SF-36, the emotional function score in the music group was significantly higher than that in the control group. CONCLUSION: This study preliminarily showed that music therapy can effectively reduce chronic pain and improve midterm quality of life after surgery.


Assuntos
Valva Aórtica/cirurgia , Dor Crônica/terapia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Valva Mitral/cirurgia , Musicoterapia , Dor Pós-Operatória/terapia , Qualidade de Vida , China , Dor Crônica/diagnóstico , Dor Crônica/fisiopatologia , Dor Crônica/psicologia , Emoções , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Percepção da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/psicologia , Fatores de Tempo , Resultado do Tratamento
7.
Arch Phys Med Rehabil ; 101(10): 1754-1762, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32445848

RESUMO

OBJECTIVES: To investigate pain catastrophizing presentations up to 6 months postoperatively and subsequent changes in pain intensity and physical function. DESIGN: Prospective observational multisite study. SETTING: Two tertiary care facilities between 2016 and 2019. PARTICIPANTS: Adult patients (N=348) undergoing a mastectomy, thoracic surgery, total knee or hip arthroplasty, spinal fusion, or major abdominal surgery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain Catastrophizing Scale scores, Defense and Veterans Pain Rating Scale, average pain intensity, and Patient Reported Outcomes Measurement Information System (PROMIS) physical function. RESULTS: Four pain catastrophizing trajectories were identified in 348 surgical patients during the 6 months of postoperative recovery: stable, remitting, worsening, and unremitting. Linear mixed-effects models found that the unremitting trajectory was associated with higher pain intensity over time. The average pain intensity of participants in the remitting trajectory was estimated to decrease at a faster rate over the 6 months after surgery than pain of other trajectories, despite participants reporting high preoperative Pain Catastrophizing Scale and pain scores. Worsening and unremitting trajectories were associated with reduced physical function. Preoperative average pain intensity scores were not associated with postoperative physical function scores, nor were participants' preoperative physical function scores associated with average pain intensity scores postoperatively. Prolonged hospitalization, smoking, and preoperative opioid prescriptions were associated with the unremitting trajectory. CONCLUSIONS: Findings suggest that preoperative pain catastrophizing scores alone may not be adequate for estimating long-term patient-reported outcomes during postoperative rehabilitation. Pain catastrophizing has a dynamic presentation and is associated with changes in pain intensity and physical function up to 6 months postoperatively. Routine assessments can inform the delivery of early interventions to surgical patients at risk of experiencing a pain catastrophizing trajectory associated with suboptimal outcomes during rehabilitation.


Assuntos
Catastrofização/epidemiologia , Dor Pós-Operatória/epidemiologia , Adulto , Idoso , Catastrofização/fisiopatologia , Comorbidade , Feminino , Nível de Saúde , Humanos , Estudos Longitudinais , Masculino , Saúde Mental , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/fisiopatologia , Medidas de Resultados Relatados pelo Paciente , Desempenho Físico Funcional , Estudos Prospectivos , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs
8.
Medicine (Baltimore) ; 99(20): e20213, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443348

RESUMO

BACKGROUND: Effective postoperative analgesia may enhance early rehabilitation after total knee arthroplasty (TKA). The purpose of this study is to perform a randomized controlled trial to compare the efficiency of adductor canal block (ACB) with periarticular infiltration (PAI) versus PAI alone for early postoperative pain treatment after TKA. METHODS: After institutional review board approval, written informed consent was obtained from patients undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 30 mL of 0.5% ropivacaine and 100 mcg of clonidine. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. The primary outcome was morphine consumption in the first 24 hours. Secondary outcomes included pain scores, morphine consumption at 48 hours, opioid-related side effects (post-operative nausea/vomiting, sedation scores), functional outcomes, quadriceps strength, and length of hospital stay. CONCLUSIONS: For the present trial, we hypothesized that patients receiving adductor canal block + PAI would have significantly lower morphine consumption and pain scores after surgery. TRIAL REGISTRATION NUMBER: researchregistry5490.


Assuntos
Artroplastia do Joelho/efeitos adversos , Bloqueio Nervoso/normas , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgésicos Opioides/uso terapêutico , Anti-Inflamatórios não Esteroides/uso terapêutico , Artroplastia do Joelho/métodos , Bupivacaína/uso terapêutico , Protocolos Clínicos , Famotidina/uso terapêutico , Feminino , Humanos , Masculino , Meloxicam/uso terapêutico , Pessoa de Meia-Idade , Bloqueio Nervoso/métodos , Bloqueio Nervoso/estatística & dados numéricos , Oxicodona/uso terapêutico , Manejo da Dor/métodos , Dor Pós-Operatória/fisiopatologia , Projetos Piloto
9.
Am J Obstet Gynecol ; 223(2): 271.e1-271.e8, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32387326

RESUMO

BACKGROUND: Improving the patient experience, controlling pain with nonopiate therapies, and preparing for value-based reimbursement are increasingly important foci for both physicians and hospitals. OBJECTIVE: We aimed to determine whether the addition of music and a natural landscape image to postoperative hospital rooms would result in improved pain and satisfaction scores among inpatients undergoing pelvic reconstructive surgery. STUDY DESIGN: This randomized controlled trial was approved by an Institutional Review Board. Eligible candidates were 18-85 years old, English speaking, and scheduled to undergo native tissue vaginal vault suspension for symptomatic pelvic organ prolapse. Patients with history of a chronic pain or substance abuse were excluded. Subjects were advised that the purpose of the study was to assess the effect of changes to the hospital environment on patient experience but were blinded to their group and intervention details. Changes included a landscape image mounted to the wall and access to a speaker with preprogrammed music selections. The intervention group was instructed to listen to their preferred music for a minimum of 2 30-minute sessions postoperatively. The control group had a standard hospital room, without music or landscape. All patient rooms were private. The primary outcome was the visual analog scale for pain in the morning of postoperative day 1. Secondary outcomes included narcotic use, likelihood to refer family to the same hospital facility, satisfaction with care and the hospital, and perception of a healing environment. A sample size of 43 subjects per arm was calculated to detect a difference of 10 mm in visual analog scale pain score. RESULTS: A total of 133 subjects were enrolled; primary outcome data were available for 92 (46 per arm). The mean age was 63.8 (standard deviation, 9.5) years, median Charlson comorbidity score was 2 (min, 0; max, 7), and 94.6% of subjects were white. On postoperative day 1, median visual analog scale pain scores were low (28.8 mm [0, 86]; 24.5 mm [0, 81]) and did not differ between intervention and control, respectively (P=.57). Total morphine equivalents (P=.817) and nursing pain scores (P=.774) were also similar. However, the intervention group displayed a higher likelihood to refer family members to the hospital (98 mm (47, 100); 96 mm (65, 100); P=.037). At postoperative 2 weeks, the intervention group indicated higher satisfaction with their care (98 mm, (34, 100); 95 mm (42, 100); P=.032), the hospital (98 mm (71, 100); 94 mm (6, 100); P=.004), and the healing environment provided during their stay (98 mm; 92 mm (19, 100); P=.020) than those in the standard hospital rooms. CONCLUSION: In this randomized trial, we found music and landscape imagery did not substantially affect postoperative pain scores; however, they had a positive effect on the postoperative experience. Furthermore, this effect appeared to broaden 2 weeks after surgery. Given the importance of value-based care, interventions such as these should be emphasized to enhance patient satisfaction, quality scores, and overall well-being.


Assuntos
Decoração de Interiores e Mobiliário , Música , Dor Pós-Operatória/fisiopatologia , Satisfação do Paciente , Quartos de Pacientes , Prolapso de Órgão Pélvico/cirurgia , Cuidados Pós-Operatórios , Idoso , Analgésicos Opioides/uso terapêutico , Arte , Meio Ambiente , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico
10.
Tumori ; 106(5): 388-391, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32326829

RESUMO

OBJECTIVE: Erector spine plane block (ESPB) is a newly defined regional anesthesia technique performed by injection of local anesthetic beneath the erector spine muscle. We tested ESPB as a regional rescue analgesia bedside technique to be performed in the thoracic surgical ward, reporting a 7-patient case series. METHODS: We report our experience in rescue analgesia after thoracic surgery. During the postoperative stay, numeric rating scale (NRS) score >3 and inability to perform physiotherapy or effective cough due to postoperative pain represented the criteria for proposing rescue analgesia with ESPB. NRS at rest and during movements was recorded; blood gas analysis and spirometry were performed to evaluate PaO2/FiO2 (P/F), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1) before ESPB execution. After performing the ESPB, static and dynamic NRS, P/F, and FVC and FEV1 were recorded at 40 minutes and 80 minutes. RESULTS: NRS had a reduction at rest and in dynamic assessment. The P/F did not improve but spirometric measures improved. FVC had a relevant improvement only after 80 minutes; FEV1 was increased after 40 minutes. CONCLUSION: The use of ESPB as postoperative rescue analgesia can offer several advantages due to effective rescue analgesia and safety that makes it easy to perform in the thoracic surgical ward or in an outpatient clinic setting.


Assuntos
Anestésicos Locais/uso terapêutico , Músculo Esquelético/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Procedimentos Cirúrgicos Torácicos/métodos , Adulto , Idoso , Analgesia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/inervação , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/fisiopatologia , Coluna Vertebral/efeitos dos fármacos , Coluna Vertebral/fisiopatologia , Ultrassonografia de Intervenção
11.
Anticancer Res ; 40(4): 2231-2238, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32234919

RESUMO

AIM: Acute post-operative pain following modified radical mastectomy (MRM) in patients with breast cancer is challenging for anesthesiologists. This study aimed to prospectively compare the quality outcome of interfascial plane blocks performed with ultrasound guidance, and evaluate the consequences of sharing tasks with the breast surgeon. PATIENTS AND METHODS: The study involved 255 patients scheduled for unilateral MRM, who were divided into two groups: Pecs group: General anesthesia plus ultrasound-guided modified pectoral nerves blocks type I and II, including serratus and parasternal infiltration according to surgical requirements; and Control group: general anesthesia only. Quality was evaluated based on perioperative opioid consumption, reported pain intensity, rescue analgesic requirement, side-effects and length of hospital stay. Moreover, a breast surgeon with expertise in ultrasound-guided breast biopsy was trained to perform the blocks. The patient benefits from regional anesthesia delivered by a non-anesthesiologist were assessed. RESULTS: Significant reductions were noted in all of the following: Intraoperative opioid consumption (p<0.001), Numerating Rating Scale pain scores taken 0 and 24 h after surgery (p<0.001), post-operative analgesic administration (p<0.001), nausea and vomiting at 0, 6, and 12-h intervals (p<0.05), and hospital stay (p<0.001) were observed in the Pecs group compared with the control group. Furthermore, data obtained from patients receiving the block from the surgeon showed comparable benefits with no complications. CONCLUSION: Interfascial plane blocks may be an important alternative protocol in MRM, enhancing patient safety and cost benefits. Improvements in cross-disciplinary expertise through flexibility in the training of professionals with other backgrounds may provide effective analgesia and favorable outcomes.


Assuntos
Anestesia Geral/métodos , Neoplasias da Mama/cirurgia , Mama/cirurgia , Mastectomia Radical Modificada/métodos , Bloqueio Nervoso/métodos , Nervos Torácicos/fisiopatologia , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Anestesiologistas , Mama/fisiopatologia , Neoplasias da Mama/fisiopatologia , Feminino , Humanos , Mastectomia Radical Modificada/efeitos adversos , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Estudos Prospectivos
12.
PLoS One ; 15(3): e0229898, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32142529

RESUMO

OBJECTIVES: To test the feasibility of a randomized controlled study design comparing epidural analgesia (EDA) with continuous wound infiltration (CWI) in respect to postoperative complications and mobility to design a future multicentre randomized controlled trial. DESIGN, SETTING, PARTICIPANTS: CWI has been developed to address drawbacks of EDA. Previous studies have established the equivalent analgesic potential of CWI compared to EDA. This is a single centre, non-blinded pilot randomized controlled trial at a tertiary surgical centre. Patients undergoing elective non-colorectal surgery via a midline laparotomy were randomized to EDA or CWI. Endpoints included recruitment, feasibility of assessing postoperative mobility with a pedometer and morbidity. No primary endpoint was defined and all analyses were explorative. INTERVENTIONS: CWI with local anaesthetics (experimental group) vs. thoracic EDA (control). RESULTS: Of 846 patients screened within 14 months, 71 were randomized and 62 (31 per group) included in the intention-to-treat analysis. Mobility was assessed in 44 of 62 patients and revealed no differences within the first 3 postoperative days. Overall morbidity did not differ between the two groups (measured via the comprehensive complication index). Median pain scores at rest were comparable between the two groups, while EDA was superior in pain treatment during movement on the first, but not on the second and third postoperative day. Duration of preoperative induction of anaesthesia was shorter with CWI than with EDA. Of 17 serious adverse events, 3 were potentially related to EDA, while none was related to CWI. CONCLUSION: This trial confirmed the feasibility of a randomized trial design to compare CWI and EDA regarding morbidity. Improvements in the education and training of team members are necessary to improve recruitment. TRIAL REGISTRATION: DRKS00008023.


Assuntos
Traumatismos Abdominais/cirurgia , Analgesia Epidural/métodos , Anestesia Local/métodos , Anestésicos Locais/administração & dosagem , Traumatismos Abdominais/tratamento farmacológico , Traumatismos Abdominais/fisiopatologia , Analgesia Epidural/efeitos adversos , Anestesia Local/efeitos adversos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Humanos , Laparotomia/normas , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Medição da Dor/métodos , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/prevenção & controle , Projetos Piloto , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório
13.
Sci Rep ; 10(1): 3761, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32111916

RESUMO

Analgesic effect of transversus abdominis plane block (TAP block) in lower major abdominal laparoscopic surgery with about 5 cm of maximum surgical scar has been controversial. We hypothesized that TAP block has benefits, so the analgesic effect of TAP block after robot-assisted laparoscopic prostatectomy (RALP) was evaluated. One hundred patients were enrolled in this prospective, double-blinded, randomized study. Standardized general anesthesia with wound infiltration on camera port and fentanyl dose limit of 3 µg/kg was provided. Ultrasound-guided, single-shot subcostal TAP block with either 0.375% ropivacaine (Ropivacaine group, 48 patients) or normal saline (Control group, 52 patients) was performed by anesthesiologist in charge (34 anesthesiologists) after surgical procedure. Pain score using numerical rating scale (NRS) and postoperative intravenous fentanyl were evaluated for the first 24 postoperative hours. Median values (interquartile range) of NRS scores when the patients were transferred to post-anesthesia care unit (PACU) were 5 (2-7) in Ropivacaine group and 6 (4-8) in Control group at rest (P = 0.03), 5 (2-8) in Ropivacaine group and 7 (5-8) in Control group during movement (P < 0.01). These significant differences disappeared at the time of discharging PACU. Fentanyl doses for the first 24 postoperative hours were 210 µg (120-360) in Ropivacaine group and 200 µg (120-370) in Control group (P = 0.79). These results indicated that subcostal TAP block by anesthesiologists of varied level of training reduced postoperative pain immediate after RALP. TAP block had fundamental analgesic effect, but this benefit was too small to reduce postoperative 24-hour fentanyl consumption.


Assuntos
Anestesia Geral , Fentanila/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Prostatectomia , Procedimentos Cirúrgicos Robóticos , Ropivacaina/administração & dosagem , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/fisiopatologia , Período Pós-Operatório , Estudos Prospectivos
14.
J Acupunct Meridian Stud ; 13(3): 104-109, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32205274

RESUMO

OBJECTIVES: The objective of this crossover clinical study was to evaluate the effectiveness of Energy Regulation with Acupuncture in clinical occurrences in impacted lower third molar surgeries. METHODS: The sample consisted of 22 patients with two impacted third molars, in symmetrical position; divided into two groups: Test Group (TG) with Real Energy Regulation Group and Sham Group (SG) with Acupuncture without Energy Regulation function. The extraction was performed 30 days apart. Energy flow (Ryodoraku Method) and energy regulation performed before extraction were measured. Heart Rate (HR) and Blood Pressure (BP) were evaluated before and after energy regulation and after surgery, residual edema was measured by facial measurements (angle of the mandible to tragus (A-T); angle of the mandible to labial commissure (A-LC); angle of the mandible to the wing of the nose (A-WN); angle of the mandible to the corner of the eye (A-CE); angle of the mandible to the chin (A-C); and mouth opening by the interincisal distance, before and after seven days of surgery. To quantify intraoperative bleeding (ml), blood was aspirated along with the saline solution using a portable vacuum pump adaptor. The amount of saline solution used was subtracted from the final amount of aspirated fluid. RESULTS: Mean of bleeding was lower in TG (p = 0.0392). There were significant differences between groups in facial distances: A-LC (p = 0.010), A-WN (p = 0.030) and A-C (p = 0.008). CONCLUSION: Energy regulation with real acupuncture was effective in reducing postoperative residual edema and intraoperative bleeding.


Assuntos
Terapia por Acupuntura , Dente Serotino/cirurgia , Dor Pós-Operatória/terapia , Adulto , Feminino , Hemorragia , Humanos , Masculino , Dente Serotino/irrigação sanguínea , Dor Pós-Operatória/fisiopatologia , Adulto Jovem
15.
Trials ; 21(1): 163, 2020 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-32046764

RESUMO

BACKGROUND: Postoperative pain is common after nasal endoscopic surgery. It interferes with the quality of sleep and delays postoperative recovery. Acupuncture is an effective tool for pain management. However, electroacupuncture specifically for the relief of postoperative pain after nasal endoscopic surgery has not yet been studied in a randomized controlled trial. METHODS/DESIGN: This randomized sham-controlled patient- and assessor-blind pilot trial has been designed to evaluate the efficacy and safety of electroacupuncture in managing postoperative pain following nasal endoscopic surgery to treat sinusitis due to nasal polyps. Altogether, 30 participants will be randomly allocated to an electroacupuncture or non-invasive sham control in a 1:1 ratio. Treatment will occur within 2 h before the operation, immediately after the operation upon arrival in the recovery ward, and once daily for 3 days. The primary outcome is the pain numerical rating scale, which will be analyzed using the area under the curve. The secondary outcome measures include heart rate and blood pressure after the operation, sleep quality during the hospital stay (actigraph), quality of recovery, and the 36-item short form health survey. This trial will use an intention-to-treat analysis. DISCUSSION: This pilot randomized controlled trial will explore the feasibility of the further clinical application of electroacupuncture for the management of postoperative pain. It will inform the design of a further full-scale trial. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1900024183. Registered on 29 June 2019.


Assuntos
Eletroacupuntura , Endoscopia/efeitos adversos , Procedimentos Cirúrgicos Nasais/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Adolescente , Adulto , Pressão Sanguínea/fisiologia , Estudos de Viabilidade , Feminino , Inquéritos Epidemiológicos/estatística & dados numéricos , Frequência Cardíaca/fisiologia , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Projetos Piloto , Sono/fisiologia , Resultado do Tratamento , Adulto Jovem
16.
J Pak Med Assoc ; 70(Suppl 1)(2): S42-S48, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31981335

RESUMO

OBJECTIVE: To evaluate the Wide-Awake Local Anaesthesia with No Tourniquet (WALANT) method in fixation of distal radial fractures. METHODS: Forty patients admitted to the Jinnah Postgraduate Medical Centre, Karachi, Pakistan were recruited from March 2017 to December 2018. All patients had a distal radial fracture which was appropriate for internal fixation with a locked volar distal radial plate. The surgical site was infiltrated to achieve tumescent local anaesthesia using a solution of 0.9% normal saline and 1% lidocaine with 1:1,000,000 epinephrine. The patients were followed up until fracture union and were evaluated clinically, with goniometry, radiologically and with standard outcome scores (Mayo and qDASH). RESULTS: The patients were marginally more male than female (55% versus 45%), and mostly the dominant hand was injured (65%). The mean time to union was just over 3 months (15.2 weeks). All were united by 11 months. Good outcomes were achieved at final review with mean qDASH and Mayo scores of 13.3 and 81.6 respectively. The mean flexion and extension range at finalreview was 64 and 53 degrees respectively, and the mean grip strength was 73% when compared with the opposite side. CONCLUSIONS: The WALANT technique seems to be an acceptable and safe technique for fixation of distal radial fractures. There seem to be added benefits in terms of costs, reduced disposables, and intra-operative assessment of active movement.


Assuntos
Anestésicos Locais/uso terapêutico , Placas Ósseas , Fixação Interna de Fraturas/métodos , Dor Pós-Operatória/fisiopatologia , Fraturas do Rádio/cirurgia , Vasoconstritores/uso terapêutico , Adulto , Idoso , Anestesia Local/métodos , Artrometria Articular , Epinefrina/uso terapêutico , Feminino , Consolidação da Fratura , Força da Mão , Humanos , Lidocaína/uso terapêutico , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Torniquetes , Resultado do Tratamento , Vigília , Adulto Jovem
17.
PLoS One ; 15(1): e0222370, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31914126

RESUMO

A significant proportion of osteoarthritis (OA) patients continue to experience moderate to severe pain after total joint replacement (TJR). Preoperative factors related to pain persistence are mainly studied using individual predictor variables and distinct pain outcomes, thus leading to a lack of consensus regarding the influence of preoperative parameters on post-TJR pain. In this prospective observational study, we evaluated knee and hip OA patients before, 3 and 6 months post-TJR searching for clinical predictors of pain persistence. We assessed multiple measures of quality, mood, affect, health and quality of life, together with radiographic evaluation and performance-based tasks, modeling four distinct pain outcomes. Multivariate regression models and network analysis were applied to pain related biopsychosocial measures and their changes with surgery. A total of 106 patients completed the study. Pre-surgical pain levels were not related to post-surgical residual pain. Although distinct pain scales were associated with different aspects of post-surgical pain, multi-factorial models did not reliably predict post-surgical pain in knee OA (across four distinct pain scales) and did not generalize to hip OA. However, network analysis showed significant changes in biopsychosocial-defined OA personality post-surgery, in both groups. Our results show that although tested clinical and biopsychosocial variables reorganize after TJR in OA, their presurgical values are not predictive of post-surgery pain. Derivation of prognostic markers for pain persistence after TJR will require more comprehensive understanding of underlying mechanisms.


Assuntos
Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/cirurgia , Manejo da Dor , Dor Pós-Operatória/terapia , Idoso , Artroplastia de Substituição/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Feminino , Humanos , Articulação do Joelho/fisiopatologia , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Quadril/fisiopatologia , Osteoartrite do Joelho/fisiopatologia , Medição da Dor/métodos , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/fisiopatologia , Índice de Gravidade de Doença
18.
J Surg Res ; 249: 13-17, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31918325

RESUMO

BACKGROUND: Preoperative anxiety is a common psychological state in cancer patients before surgery, inducing stress responses after surgery. Associations between preoperative anxiety and intraoperative nociception, however, have not been evaluated well. In the present study, we investigated the relationship in patients with lung cancer undergoing thoracic surgery. MATERIALS AND METHODS: In this prospective study, 27 adult patients were enrolled. Intraoperative nociception during surgery was calculated as mean values of the nociceptive response (NR) throughout surgery. Associations between intraoperative nociception and preoperative patient characteristics including anxiety in addition to intraoperative variables were analyzed using univariate and multivariate regression analyses. RESULTS: Multiple linear regression analysis revealed that mean NR values during surgery showed a negative correlation with preoperative anxiety (ß = -0.353; P = 0.041) after adjustment for body mass index, depression, and total amount of fentanyl used during surgery. Body mass index was a confounder positively associated with mean NR during surgery. CONCLUSIONS: Intraoperative nociception is likely associated with preoperative patient characteristics, having an inverse relationship with preoperative anxiety.


Assuntos
Ansiedade/epidemiologia , Neoplasias Pulmonares/cirurgia , Nociceptividade/fisiologia , Dor Pós-Operatória/diagnóstico , Cirurgia Torácica Vídeoassistida/psicologia , Idoso , Ansiedade/fisiopatologia , Ansiedade/psicologia , Pressão Sanguínea/fisiologia , Feminino , Frequência Cardíaca/fisiologia , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/psicologia , Período Pré-Operatório , Estudos Prospectivos , Cirurgia Torácica Vídeoassistida/efeitos adversos
19.
Transplantation ; 104(4): 694-699, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31815897

RESUMO

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.


Assuntos
Dor Abdominal/prevenção & controle , Dor Aguda/prevenção & controle , Analgésicos/uso terapêutico , Anestésicos Locais/uso terapêutico , Bloqueio Nervoso , Transplante de Órgãos/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Dor Abdominal/fisiopatologia , Dor Aguda/diagnóstico , Dor Aguda/etiologia , Dor Aguda/fisiopatologia , Analgésicos/efeitos adversos , Analgésicos Opioides/efeitos adversos , Anestésicos Locais/efeitos adversos , Tomada de Decisão Clínica , Humanos , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Percepção da Dor/efeitos dos fármacos , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Resultado do Tratamento
20.
Anesth Analg ; 130(3): 574-581, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31567320

RESUMO

In recent years, there have been escalating concerns related to the opioid epidemic. With a steadily increasing opioid supply, it is critical to provide proper education to patients who are prescribed these medications. Education should be emphasized as a means of ensuring safe use and potentially as a strategy for curbing the opioid supply. Patients who undergo surgery are frequently prescribed opioids for postoperative pain; however, the content and delivery of information related to usage is inconsistent and often inadequate. Lack of education on postoperative pain management and opioid use places patients at risk for poor compliance and worse pain control. Furthermore, patients are often not properly educated on opioid-related side effects and risks or about safe behaviors when taking medications. The majority of patients are also not informed about how to store and dispose of leftover medications. Patients who are prescribed opioids require education preoperatively to cover the topics of pain management, opioid-related side effects, and risks, storage, and disposal. Evidence from various studies demonstrates that educational interventions improve knowledge and potentially lead to safer behaviors and reduced opioid use. Education can be provided in various formats with each having unique advantages and limitations.


Assuntos
Analgésicos Opioides/uso terapêutico , Manejo da Dor , Dor Pós-Operatória/prevenção & controle , Educação de Pacientes como Assunto , Analgésicos Opioides/efeitos adversos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Manejo da Dor/efeitos adversos , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/fisiopatologia , Dor Pós-Operatória/psicologia , Medição de Risco , Fatores de Risco , Resultado do Tratamento
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