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1.
Medicine (Baltimore) ; 100(15): e25531, 2021 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-33847679

RESUMO

INTRODUCTION: As the adjunctive anesthesia to propofol, both dezocine and fentanyl showed some potential for gastrointestinal endoscopy. This meta-analysis aimed to compare their efficacy and safety. METHODS: PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of dezocine versus fentanyl for the anesthesia of patients undergoing gastrointestinal endoscopy were included. RESULTS: Five RCTs involving 677 patients were included in the meta-analysis. Overall, compared with fentanyl plus propofol for gastrointestinal endoscopy, dezocine plus propofol resulted in the reduction in propofol dose(mean difference [MD] = -11.72; 95% confidence interval [CI] = -22.83 to -0.61; P = .04), awakening time (std. MD = -1.79; 95% CI = -3.31 to -0.27; P = .02) and hypopnea (risk ratio [RR] = 0.16; 95% CI = 0.06-0.41; P = .0002), but had no remarkable effect on induction time (MD = 1.20; 95% CI = -0.98 to 3.39; P = .28), postoperative pain score (MD = -0.38; 95% CI = -1.00 to 0.24; P = .24), nausea or vomiting (RR = 0.45; 95% CI = 0.10-1.98; P = .29). CONCLUSION: Dezocine plus propofol may be better for the anesthesia of gastrointestinal endoscopy than fentanyl plus propofol.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestésicos Intravenosos/administração & dosagem , Compostos Bicíclicos Heterocíclicos com Pontes/administração & dosagem , Endoscopia Gastrointestinal/efeitos adversos , Fentanila/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Propofol/administração & dosagem , Tetra-Hidronaftalenos/administração & dosagem , Adulto , Idoso , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
2.
Medicine (Baltimore) ; 100(17): e25560, 2021 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-33907103

RESUMO

ABSTRACT: The aim of this study was to assess the efficacy of combined opioids by comparing four regimens of patient-controlled epidural analgesia (PCEA) after cesarean section.Parturient patients who underwent elective or emergent cesarean section under combined spinal and epidural anesthesia from April 2013 to March 2016 were retrospectively analyzed. Based on PCEA, they were assigned to one of 4 groups: local anesthetic alone (LA), epidural single morphine administration during surgery followed by local anesthetic alone (M), local anesthetic combined with fentanyl 10 µg/h (F10), or local anesthetic combined with fentanyl 20 µg/h (F20). The primary outcome was the number of PCEA boluses used. Secondary outcomes included the use of rescue analgesia, postoperative nausea and vomiting, and postoperative pruritus.A total of 250 parturients were analyzed. Whereas the number of PCEA boluses in the LA group was significantly higher than in the other combined opioid groups on the day of surgery and postoperative day 1 (LA: 3 [1-6] and 7 [4-9] vs M: 2 [0-4] and 4 [0-7] vs F10: 1 [0-4] and 3 [0-6] vs F20: 1 [0-3] and 2 [0-8], P = .012 and 0.010, respectively), within the combined opioid groups, the number was not significantly different. Significantly fewer patients in the F20 group required rescue analgesia on postoperative day 1 and 2 (25 and 55%) than those in the M (66 and 81%) and F10 (62 and 66%) groups (P < .001 and P = .007, respectively). Postoperative nausea and vomiting and pruritus were significantly higher in the M group (P < .008 and P = .024, respectively).The results of the present study suggest that local anesthetic alone after a single administration of morphine, or local anesthetic combined with fentanyl 10 µg/h would generally be adequate for PCEA, whereas local anesthetic combined with fentanyl 20 µg/h would be suitable for conventional epidural analgesia.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Analgesia Controlada pelo Paciente/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Adulto , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Cesárea/efeitos adversos , Quimioterapia Combinada , Feminino , Fentanila/administração & dosagem , Humanos , Morfina/administração & dosagem , Medição da Dor , Dor Pós-Operatória/etiologia , Gravidez , Estudos Retrospectivos , Autoadministração , Resultado do Tratamento
3.
Br J Anaesth ; 126(5): 1038-1045, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33676727

RESUMO

BACKGROUND: Inhaled methoxyflurane for acute pain relief has demonstrated an analgesic effect superior to placebo. Data comparing methoxyflurane to an opioid are needed. The aim of this study was to determine the equi-analgesic doses of inhaled methoxyflurane vs i.v. fentanyl. Both drugs have an onset within minutes and an analgesic effect of 20-30 min. METHODS: Twelve subjects were included in a randomised, double-blinded, placebo-controlled crossover study with four treatments: placebo (NaCl 0.9%), fentanyl 25 µg i.v., fentanyl 50 µg i.v., or inhaled methoxyflurane 3 ml. The subjects reported pain intensity using the verbal numeric rating scale (VNRS) from 0 to 10 during the cold pressor test (CPT). The CPT was performed before (CPT 1), 5 min (CPT 2), and 20 min (CPT 3) after drug administration. RESULTS: Inhaled methoxyflurane and fentanyl 25 µg reduced VNRS scores significantly compared with placebo at CPT 2 (-1.14 [estimated difference in VNRS between treatment groups with 95% confidence interval {CI}: -1.50 to -0.78]; -1.15 [95% CI: -1.51 to -0.79]; both P<0.001) and CPT 3 (-0.60 [95% CI: -0.96 to -0.24]; -0.84 [95% CI: -1.20 to -0.47]; both P<0.001). There were no significant differences between the two drugs. Methoxyflurane had significantly higher VNRS scores than fentanyl 50 µg at CPT 2 (0.90 [95% CI: 0.54-1.26]; P<0.001) and CPT 3 (0.57 [95% CI: 0.21-0.94]; P<0.001). CONCLUSIONS: Inhaled methoxyflurane 3 ml was equi-analgesic to fentanyl 25 µg i.v. at CPT 2. Both resulted in significantly less pain than placebo. Fentanyl 50 µg i.v. demonstrated analgesia superior to methoxyflurane. CLINICAL TRIAL REGISTRATION: NCT03894800.


Assuntos
Analgésicos Opioides/farmacologia , Anestésicos Inalatórios/farmacologia , Fentanila/farmacologia , Metoxiflurano/farmacologia , Administração por Inalação , Administração Intravenosa , Adulto , Analgésicos Opioides/administração & dosagem , Anestésicos Inalatórios/administração & dosagem , Temperatura Baixa , Estudos Cross-Over , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Fentanila/administração & dosagem , Humanos , Masculino , Metoxiflurano/administração & dosagem , Pessoa de Meia-Idade , Dor/tratamento farmacológico , Medição da Dor , Adulto Jovem
4.
An. pediatr. (2003. Ed. impr.) ; 94(1): 36-45, ene. 2021. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-200275

RESUMO

INTRODUCCIÓN: La escala de sedación para procedimientos del Hospital Niño Jesús (ESPHNJ) no ha sido validada. PACIENTES Y MÉTODOS: Estudio analítico prospectivo bihospitalario. Se reclutaron prospectivamente pacientes ≥ 6 meses sometidos a procedimientos invasivos bajo sedoanalgesia con propofol o midazolam y fentanilo. Todos fueron monitorizados con el índice biespectral (IB). Se realizaron videos de cada procedimiento, que fueron editados y aleatorizados. Ciento cincuenta videos fueron puntuados por cuatro observadores con la ESPHNJ, la escala de sedación de la Universidad de Michigan (ESUM) y la Escala de Ramsay (ER). Dichos observadores estaban cegados al IB y al momento de administración de fármacos. Para evaluar la fiabilidad test-retest, 50 videos de los 150 iniciales seleccionados aleatorizadamente fueron reevaluados. RESULTADOS: Fueron incluidos 65 pacientes. La concordancia intraobservadores fue alta (ρ = 0,793). La ESPHNJ presentó una fiabilidad interobservador buena al comparar con la ESUM (CCI = 0,88) y con la ER (CCI = 0,86), y no hubo con el IB. La consistencia interna fue moderada (α = 0,68). La validez de constructo fue demostrada por los cambios en las puntuaciones tras administrar sedantes (p < 0,0001). La ESPHNJ tuvo muy baja correlación con el IB (r = -0,166), y correlación moderada con la ESUM (r = 0,497) y la ER (r = 0,405). En relación a la aplicabilidad, nuestro trabajo se ha empleado en dos hospitales en cinco ámbitos distintos por cuatro profesionales de diferentes categorías. CONCLUSIONES: La ESPHNJ es válida, fiable y aplicable para la monitorización de la sedación en procedimientos invasivos bajo sedoanalgesia profunda en pediatría. La ESPHNJ presenta peores propiedades que la ESUM y que la ER


INTRODUCTION: The procedural sedation scale of the Niño Jesús Hospital (Madrid) (SSPNJH) has not been validated. PATIENTS AND METHODS: A prospective analytical study was conducted in 2 hospitals on patients ≥ 6 months undergoing invasive procedures using sedation-analgesia with propofol or midazolam and fentanyl. All were monitored using the bispectral index (BIS). Videos were made of each procedure, which were then edited and randomised. A total of 150 videos were rated by four observers using the SSPNJH, the sedation scale of the University of Michigan (UMSS), and the Ramsay Scale (SR). These observers were blinded to the BIS, and at the time of drug administration. To assess test-retest reliability, 50 of the initial 150 randomly selected videos were re-assessed. RESULTS: The study included a total of 65 patients. The within-observer agreement was high (ρ = 0.793). The SSPNJH gave a good interobserver reliability when compared with the UMSS (ICC = 0.88) and the SR (ICC = 0.86), and there was none with the BIS. Internal consistency was moderate (α = 0.68). Construct validity was demonstrated by changes in scores after administering sedatives (p < 0.0001). The SSPNJH had a very low correlation with the BIS (r = -0.166), and a moderate correlation with the UMSS (r = 0.497) and the SR (r = 0.405). As regards the applicability, this scale has been used in two hospitals in five different areas by four professionals of different categories. CONCLUSIONS: The SSPNJH is valid, reliable and applicable for sedation monitoring in invasive procedures under deep sedation-analgesia in paediatric patients. The SSPNJH has worse properties than the UMSS and the SR


Assuntos
Humanos , Masculino , Criança , Reprodutibilidade dos Testes , Sedação Profunda/métodos , Hipnóticos e Sedativos/administração & dosagem , Monitorização Fisiológica/métodos , Estudos Prospectivos , Gravação em Vídeo , Fentanila/administração & dosagem , Propofol/administração & dosagem , Psicometria , Midazolam/administração & dosagem
5.
J Oncol Pharm Pract ; 27(2): 445-447, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33356990

RESUMO

The aim of this paper was to assess the drug costs of the different biotechnologies (intranasal fentanyl spray (INFS), oral transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablet (FBT)) in the treatment of breakthrough cancer pain (BTCP). We have calculated the mean drug costs (expressed in euros (€)) for patients treated for BTCP. INFS resulted the less expensive towards OTFC and FBT, with 697 440 €versus (vs.) 809 552 €vs. 779 662 €every 100 patients treated for BTCP, respectively. In conclusion, combining drug costs of different biotechnologies (INFS, OTFC and FBT) with the measure of efficacy represented by the reduction of BTCP avoided (incremental cost-effectiveness ratio, ICER), INFS resulted in better cost-effectiveness.


Assuntos
Analgésicos Opioides/economia , Dor Irruptiva/tratamento farmacológico , Dor do Câncer/tratamento farmacológico , Custos de Medicamentos , Fentanila/economia , Administração Bucal , Administração Intranasal/economia , Administração Oral , Analgésicos Opioides/administração & dosagem , Análise Custo-Benefício , Fentanila/administração & dosagem , Humanos
7.
J Opioid Manag ; 16(4): 237-238, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32886349

RESUMO

The COVID-19 ARDS appears to have worse outcomes than ARDS from other causes. It is a predictable serious complication and the key strategy is to maintain oxygenation. Adopting the prone position for conscious COVID-19 patients requiring basic respiratory support, is shown to benefit patients in terms of improving oxygenation, reducing the need for invasive ventilation and potentially even reducing mortality. Cough and myalgia are the common and most distressing symptoms seen in conscious COVID-19 patients which can impair tolerance to awake proning. Modified awake proning with application of transdermal fentanyl patch (TFP) can improve the compliance to conscious proning in COVID-19 patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Estado de Consciência , Infecções por Coronavirus/terapia , Fentanila/administração & dosagem , Pneumonia Viral/terapia , Decúbito Ventral , Betacoronavirus , Humanos , Pandemias , /virologia , Adesivo Transdérmico
8.
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
9.
J S Afr Vet Assoc ; 91(0): e1-e8, 2020 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-32787423

RESUMO

Potent opioids are known to cause negative alterations to the physiology of immobilised antelope. How these effects differ between species has not been studied. This study aimed to compare time to recumbence and effects of opioid-based immobilisation on the physiology of impala (Aepyceros melampus) and blesbok (Damaliscus pygargus phillipsi). Eight animals of each species were immobilised, with 0.09 mg/kg etorphine and 0.09 mg/kg thiafentanil respectively, in a randomised two-way cross-over study. Variables measured and analysed by means of a linear mixed model included time to recumbence, heart rate, respiratory rate, arterial blood pressure, blood gases, lactate and glucose. In blesbok, mean time to recumbence was not significantly different with either drug (2.5 minutes and 2.2 min, respectively), but in impala thiafentanil achieved a shorter time to recumbence (2.0 min) than etorphine (3.9 min). Mean heart rates of immobilised impala were within reported physiological limits, but lower in immobilised blesbok when both opioids were used (35 beats/min to 44 beats/min vs. 104 ± 1.4 beats/min resting heart rate). Impala developed severe respiratory compromise and hypoxaemia from both opioids (overall mean PaO2 values ranged from 38 mmHg to 59 mmHg over 30 min). In contrast, blesbok developed only moderate compromise. Therefore, significantly different species-specific physiological responses to potent opioid drugs exist in blesbok and impala. Given that these different responses are clinically relevant, extrapolation of immobilising drug effects from one species of African ungulate to another is not recommended.


Assuntos
Analgésicos Opioides/farmacologia , Antílopes/fisiologia , Etorfina/farmacologia , Fentanila/análogos & derivados , Hipnóticos e Sedativos/farmacologia , Imobilização/veterinária , Analgésicos Opioides/administração & dosagem , Animais , Estudos Cross-Over , Etorfina/administração & dosagem , Feminino , Fentanila/administração & dosagem , Fentanila/farmacologia , Hipnóticos e Sedativos/administração & dosagem , Distribuição Aleatória , Especificidade da Espécie
10.
Medicine (Baltimore) ; 99(31): e21435, 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32756154

RESUMO

INTRODUCTION: The population of obese individuals is increasing worldwide, and as a result, the number of mothers with super morbid obesity undergoing cesarean sections is also increasing. However, little is known about which anesthetic technique is appropriate for cesarean sections of super morbidly obese parturients. PATIENT CONCERNS: A 35-year-old woman with body mass index 61.3 kg/m at a gestational age of 37 weeks. DIAGNOSIS: The patient was super morbidly obese parturient. INTERVENTIONS: Spinal anesthesia was performed. A spinal needle was inserted into the L4-5 interspinous space in the sitting position. After confirmation of cerebrospinal fluid, 0.5% hyperbaric bupivacaine 9 mg and fentanyl 20 µg were injected into the subarachnoid space. OUTCOMES: After the administration of spinal anesthetics, the nerve block to the T8 dermatome level was confirmed, surgery was performed, and the fetus was delivered. The patient's vital signs were stable until the end of the operation. CONCLUSION: There is no established strategy for selecting a method of anesthesia in patients with morbid obesity (body mass index 40 kg/m or more). For this reason and considering the amount of bupivacaine used for spinal anesthesia, we wanted to share our experience with spinal anesthesia for cesarean section in a super morbidly obese parturients.


Assuntos
Anestesia Obstétrica/métodos , Raquianestesia/instrumentação , Cesárea/métodos , Obesidade Mórbida/cirurgia , Adulto , Analgésicos Opioides/administração & dosagem , Anestesia Epidural/métodos , Anestesia Obstétrica/tendências , Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Índice de Massa Corporal , Bupivacaína/administração & dosagem , Feminino , Fentanila/administração & dosagem , Idade Gestacional , Humanos , Injeções Espinhais , Agulhas , Obesidade Mórbida/epidemiologia , Alta do Paciente/normas , Gravidez
11.
Lima; IETSI; 24 ago. 2020.
Não convencional em Espanhol | LILACS, BRISA/RedTESA | ID: biblio-1119647

RESUMO

INTRODUCCIÓN: Uno de los mayores intereses en el campo de la salud y en torno a la pandemia de COVID-19 es el desarrollo de estrategias para reducir la transmisión de la infección por SARS-CoV-2, incluyendo la protección de los trabajadores de salud, grupo de riesgo frente a la infección por este virus (Ng et al. 2020). La extubación es un procedimiento generador de aerosoles debido a la respuesta refleja del sistema respiratorio durante esta actividad, manifestada como la presencia de tos en algunos pacientes a los que se les realiza destete del ventilador mecánico (Brewster et al. 2020). Realizar la extubación requiere la proximidad de los trabajadores de salud con los pacientes, los cuales, incluyendo los casos de pacientes con COVID-19, suelen seguir siendo infecciosos al momento de la extubación (Brewster et al. 2020, Zhou et al. 2020, Ng et al. 2020), por lo que realizar esta actividad incrementaría la probabilidad de transmisión de esta infección viral. Ante ello, diversos grupos relacionados a la anestesiología señalan como útil el empleo de medicación que reduzca la generación de tos durante la extubación, que, junto a otras medidas de protección, disminuiría la probabilidad de transmisión de la infección por SARS-CoV-2 (Brown et al. 2020, Cook et al. 2020, D'Silva et al. 2020, Tan Li et al 2020). En EsSalud, se dispone de lidocaína y fentanilo, medicamentos descritos en la literatura científica como útiles para reducir la tos en pacientes a los que se les realizará el destete de la ventilación mecánica. Sin embargo, algunos especialistas argumentan que estos agentes sedantes podrían causar depresión respiratoria, retraso en el despertar e incrementar el riesgo de delirio si son administrados por periodos largos. Adicionalmente, los especialistas argumentan que dexmedetomidina es una alternativa que ofrecería la ventaja un despertar más rápido y una menor incidencia de delirio, además de reducir la incidencia de tos durante la extubación, estos efectos facilitarían la extubación del paciente y disminuiría la transmisión del SARS-CoV-2 al equipo médico tratante en la UCI. En ese sentido, el presente documento tuvo como objetivo evaluar la eficacia y seguridad de dexmedetomidina comparado con lidocaína y fentanilo para destete de ventilación mecánica invasiva en pacientes con COVID-19. TECNOLOGÍA DE INTERÉS: Dexmedetomidina es un agonista selectivo de los receptores alfa-2 con efectos ansiolíticos, sedantes (mediados por la inhibición del locus coeruleus, el núcleo noradrenérgico predominante, situado en el tronco cerebral) y analgésicos, produciendo además un efecto simpaticolítico al disminuir la liberación de noradrenalina en las terminaciones nerviosas simpáticas. METODOLOGÍA: Se buscó la evidencia disponible al 24 de agosto del 2020 en las siguientes bases de datos bibliográficas: PubMed, The Cochrane Library y LILACS. Asimismo, se realizó una búsqueda en sitios web pertenecientes a grupos que realizan evaluaciones de tecnologías sanitarias y guías de práctica clínica, incluyendo: The Canadian Agency for Drugs and Technologies in Health (CADTH), Scottish Medicines Consortium (SMC), The National Institute for Health and Care Excellence (NICE), Institute for Quality and Efficiency in Healthcare (IQWiG), Haute Authorité de Santé (HAS), Institute for Clinical and Economic Review (ICER) y el portal BRISA (Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas). Adicionalmente, se realizó búsqueda de evidencia en sitios web de organizaciones internacionales en anestesiología o de instituciones que estén desarrollando protocolos para el manejo de pacientes con COVID-19. RESULTADOS: En la búsqueda de la evidencia no se identificaron estudios que evalúen la eficacia y seguridad de dexmedetomidina, comparado con lidocaína y fentanilo, para el destete de ventilación mecánica invasiva, en pacientes con COVID-19. Sin embargo, se identificaron: tres GPC o consensos de expertos elaborados por la Safe Airway Society, Alfred ICU y la Difficult Airway Society e instituciones colaboradoras; una RS con metaanálisis en red realizada por Tung et al., así como dos ensayos clínicos controlados, aleatorizados (ECA) que no fueron incluidos en la RS. Se debe precisar que esta RS y estos ECA no fueron realizados en la población de interés del presente reporte breve (pacientes con COVID-19); por lo que fueron incluidos como evidencia indirecta. CONCLUSIONES: En el presente documento, se evaluó la mejor evidencia científica disponible hasta la actualidad sobre eficacia y seguridad de dexmedetomidina comparado con lidocaína y fentanilo para destete de ventilación mecánica en pacientes con COVID-19. Se encontraron: tres GPC o consensos de expertos, una RS y dos ECA. La RS y los ECA incluidos aportan al reporte breve como evidencia indirecta; al no haber sido desarrollados en pacientes con COVID-19. Las guías de la Safe Airway Society (SAS), Alfred ICU y de la Difficult Airway Society (DAS) e instituciones colaboradoras que fueron elaboradas para dar recomendaciones para el proceso de extubación en pacientes con COVID-19, hacen mención a dexmedetomidina (SAS, Alfred ICU), opioides como el fentanilo (SAS y DAS) y la lidocaína (SAS, DAS) para reducir la tos durante el proceso de extubación, aunque precisan la ausencia de evidencia sobre el uso de este medicamentos en pacientes con COVID-19, señalando que se debe evaluar el balance riesgo-beneficio para el uso de los mismos. En general, las recomendaciones descritas en estos documentos proceden de consensos por opinión de expertos, y no establecen una preferencia de un medicamento sobre los otros. En cuanto a los resultados de la RS con MA en red de Tung et al., y los ECA de Kothari et al., y Hu et al., no han podido encontrar evidencia que apoye la hipótesis que el efecto de la dexmedetomidina sea superior al de lidocaína y fentanilo sobre el manejo de la tos (esto es, no se encontraron diferencias entre estos). Estos resultados deben ser interpretados con cautela debido a que la población de estudio de los mismos no son pacientes COVID-19. No obstante, la información que proporcionan puede ayudar a tener una idea del efecto que se podría esperar con el uso de cada uno de los medicamentos mencionados, tanto en eficacia como en seguridad. Al respecto, frente a una ausencia de diferencia entre dexmedetomidina en comparación con lidocaína y fentanilo, se tiene evidencia que la primera tiene un mayor riesgo de bradicardia que los dos últimos. Esto se condice con la literatura previa acerca de dicho medicamento (dexmedetomidina), donde además se describe que los adultos mayores y personas con comorbilidades presentan una mayor proporción de eventos de bradicardia atribuibles al uso de dexmedetomidina lo que, siendo que estos grupos poblacionales son los más afectados por COVID-19, sería esperable una mayor presencia de bradicardia como evento adverso en pacientes con COVID-19 que reciben dexmedetomidina, lo que llama a la precaución cuando se considera el uso de esta tecnología en estos pacientes. De este modo, la mejor evidencia disponible a la fecha (24 de agosto del 2020), procedente de tres GPC o consensos de expertos, una RS con metaanálisis en red y dos ECA, apunta a que el balance de riesgo-beneficio del empleo de dexmedetomidina comparado con el uso de lidocaína o fentanilo, en la reducción de la tos durante el destete de ventilación mecánica en pacientes con COVID-19 es de alta incertidumbre, especialmente por el hecho que la dexmedetomidina está asociada a un mayor riesgo de reacciones adversas frente a los otros dos medicamentos, especialmente en lo referente a bradicardia. Por ello, con este cuerpo de evidencia, el IETSI no ha encontrado sustento técnico que pueda apoyar una recomendación a favor del uso de dexmedetomidina por sobre el de lidocaína o fentanilo en pacientes COVID-19 para reducir la tos al momento de la extubación.


Assuntos
Humanos , Respiração Artificial/métodos , Desmame do Respirador/instrumentação , Fentanila/administração & dosagem , Infecções por Coronavirus/tratamento farmacológico , Dexmedetomidina/administração & dosagem , Betacoronavirus/efeitos dos fármacos , Lidocaína/administração & dosagem , Avaliação da Tecnologia Biomédica , Avaliação em Saúde
12.
Rev Esp Salud Publica ; 942020 Jul 28.
Artigo em Espanhol | MEDLINE | ID: mdl-32719309

RESUMO

OBJECTIVE: Immediate-release fentanyl is indicated in the treatment of breakthrough pain in cancer patients who already receive opioids as background chronic analgesia. According to an alert issued by the Spanish Agency of Medicines, its consumption under non-authorized conditions has alarmingly increased in recent years, with a greater risk of abuse and dependence. The main objective of this study is to compare the off-label use of immediate-release fentanyl in our hospital during 2014 and 2017. METHODS: Retrospective cross-sectional descriptive study in which immediate-release fentanyl prescriptions were compared in adult patients admitted during 2014 and 2017 in a group 5 hospital. Variables were collected by the electronic medical record. The association study between qualitative variables was calculated using the χ2 test, and quantitative variables with the t-student test. RESULTS: In 2014, 0.43 immediate-release fentanyl prescriptions were made in our center for every 100 admissions, and in 2017 0.54/100 admissions. 22.1% (n=34) prescriptions were off-label in 2014, while in 2017 31.8% (n=76) (p=0.034). Both years, the most frequent off-label indications were healing of ulcers and wounds and non-cancer chronic pain. CONCLUSIONS: The use of immediate-release fentanyl in the hospital setting has considerably increased in comparison to 2014, as well as its off-label use.


Assuntos
Analgésicos Opioides/administração & dosagem , Dor Irruptiva/tratamento farmacológico , Fentanila/administração & dosagem , Prescrição Inadequada/tendências , Uso Off-Label/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/etiologia , Padrões de Prática Médica/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Estudos Transversais , Liberação Controlada de Fármacos , Feminino , Fentanila/uso terapêutico , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Estudos Retrospectivos , Espanha
13.
PLoS One ; 15(7): e0235461, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32649717

RESUMO

OBJECTIVE: Intranasal fentanyl (INF) quickly and noninvasively relieves severe pain, whereas intravenous hydromorphone (IVH) reliably treats severe cancer pain but requires vascular access. The trial evaluated the efficacy of INF relative to IVH for treating cancer patients with severe pain in an emergency department (ED) setting. METHODS: We randomized 82 patients from a comprehensive cancer center ED to receive INF (n = 42) or IVH (n = 40). Eligible patients reported severe pain at randomization (≥7, scale: 0 "none" to 10 "worst pain"). We conducted non-inferiority comparisons (non-inferiority margin = 0.9) of pain change from treatment initiation (T0) to one hour later (T60). T0 pain ratings were unavailable; therefore, we estimated T0 pain by comparing 1) T60 ratings, assuming similar group T0 ratings; 2) pain change, estimating T0 pain = randomization ratings, and 3) pain change, with T0 pain = 10 (IVH group) or T0 pain = randomization rating (INF group). RESULTS: At T60, the upper 90% confidence limit (CL) of the mean log-transformed pain ratings for the INF group exceeded the mean IVH group rating by 0.16 points (>pain). Substituting randomization ratings for T0 pain, the lower 90% CL of mean pain change in the INF group extended 0.32 points below (

Assuntos
Analgésicos Opioides/administração & dosagem , Dor do Câncer/tratamento farmacológico , Fentanila/administração & dosagem , Neoplasias/tratamento farmacológico , Administração Intranasal , Administração Intravenosa , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Dor do Câncer/complicações , Dor do Câncer/patologia , Serviço Hospitalar de Emergência , Feminino , Fentanila/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Neoplasias/patologia
14.
Spine (Phila Pa 1976) ; 45(15): 1017-1023, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32675598

RESUMO

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To evaluate the efficacy of the postoperative single-shot bolus of epidural Fentanyl and Bupivicaine in providing pain relief postlumbar decompression surgery. SUMMARY OF BACKGROUND DATA: Despite lumbar decompression's success in alleviating symptoms of sciatica, radiculopathy, and neurogenic claudication, transient back and buttock pain has been a common complaint postoperatively. Providing good postoperative pain alleviation predicts patient's quality of recovery. METHODS: We performed a randomized, double-blinded, clinical trial. Forty-five patients scheduled for lumbar decompression for a year's period who were randomly assigned to receive a postoperative bolus of 10-mL solution of 50 mcg of Fentanyl, 0.125% Bupivacaine, and 0.9% saline solution via an intraoperatively placed epidural catheter immediately after wound closure, before dressing application. Facial pain scale scores (from 0 to 10) were measured at three time points after surgery (fully awake at recovery room, transfer to ward, first postoperative day). Postoperative need for oral analgesics, time to independent ambulation, associated adverse events, and time to hospital discharge were also evaluated. RESULTS: Pain scores were noted to be significantly lower at all time points in the epidural group (P < 0.001). In turn, they also received less on-demand oral pain medications than those in the control group (P = 0.000). The mean time to ambulation was 0.09 days in the epidural group and 0.91 days in the decompression-alone group (P = 0.000). Criteria for hospital discharge were usually met on Day 0 in the epidural and Day 1 in the control group (P = 0.000). Within the study period, only one infection was noted in the epidural group which necessitated additional lumbar spine surgery (4.3%). No adverse events or complications related to Fentanyl use were observed. CONCLUSIONS: A postoperative bolus of Fentanyl and Bupivacaine is effective in reducing early postoperative pain without the related complications of opiod administration. LEVEL OF EVIDENCE: 2.


Assuntos
Analgesia Epidural/métodos , Bupivacaína/administração & dosagem , Descompressão Cirúrgica/tendências , Fentanila/administração & dosagem , Vértebras Lombares/cirurgia , Dor Pós-Operatória/tratamento farmacológico , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/tendências , Analgésicos Opioides/administração & dosagem , Descompressão Cirúrgica/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Dor Pós-Operatória/etiologia , Estudos Prospectivos
15.
J Card Surg ; 35(7): 1525-1530, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32579779

RESUMO

BACKGROUND: The optimum cardiac surgical pain management has known to maintain hemodynamic stability and, reduces respiratory and cardiovascular complications. Postoperative parasternal intercostal block has shown to reduce postoperative analgesic consumption after cardiac surgery. Therefore, this study sought to investigate the effectiveness of the preoperative ultrasound guided parasternal block in reducing postoperative pain after cardiac surgery. METHODS: This was a randomized, prospective, interventional, single blind study comprised of 90 adult patients scheduled for cardiac surgery involving sternotomy. Preoperatively and postoperatively, 0.25% bupivacaine administered in 4 mL aliquots into the anterior (2nd-6th) intercostal spaces on each side about 2 cm lateral to the sternal edge with a total volume of 40 mL under ultrasound guidance and direct vision, respectively. Postoperative pain was rated according to visual analogue scale. Secondary outcomes included intraoperative and postoperative fentanyl consumptions, dosages of rescue medications, and time to extubation. MAIN RESULTS: There was no significant differences in visual analogue score visual analogue score at all time points till 24 hours postoperatively. Intraoperative fentanyl requirements (microgram/kg) before cardiopulmonary bypass was significantly lower in pre-incisional group than the post-incisional group (0.16 ± 0.43 vs 0.68 ± 0.72; P = .0001). Furthermore, there were no significant difference in total fentanyl requirement (7.20 ± 2.66 vs 8.37 ± 3.13; P = .06) and tramadol requirement (0.02 ± 0.15 vs 0.07 ± 0.26; P = .28) within first 24 hours. However, time to extubation was significantly higher in the preoperative group (P = .02). CONCLUSIONS: Preoperative and postoperative parasternal intercostal block provide comparable pain relief during the postoperative period.


Assuntos
Bupivacaína/administração & dosagem , Procedimentos Cirúrgicos Cardíacos , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/métodos , Esterno/inervação , Cirurgia Assistida por Computador/métodos , Ultrassonografia de Intervenção/métodos , Adulto , Feminino , Fentanila/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Estudos Prospectivos , Esternotomia , Tramadol/administração & dosagem , Resultado do Tratamento , Adulto Jovem
16.
BMJ Support Palliat Care ; 10(3): 343-349, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32546559

RESUMO

BACKGROUND: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. AIMS AND OBJECTIVES: To investigate UK and Ireland clinicians' experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. METHODS: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. RESULTS: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. CONCLUSIONS: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.


Assuntos
Cuidadores , Vias de Administração de Medicamentos , Cuidados Paliativos/métodos , Padrões de Prática Médica/estatística & dados numéricos , Assistência Terminal/métodos , Administração Bucal , Administração Sublingual , Analgésicos não Narcóticos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Fentanila/administração & dosagem , Clínicos Gerais , Cuidados Paliativos na Terminalidade da Vida/métodos , Hospitais para Doentes Terminais , Humanos , Hipnóticos e Sedativos/administração & dosagem , Irlanda/epidemiologia , Lorazepam/administração & dosagem , Metotrimeprazina/administração & dosagem , Antagonistas Muscarínicos/administração & dosagem , Enfermeiras Especialistas , Medicina Paliativa , Pandemias , Médicos , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Inquéritos e Questionários , Telemedicina/métodos , Adesivo Transdérmico , Reino Unido/epidemiologia
17.
Medicine (Baltimore) ; 99(22): e20298, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32481399

RESUMO

Continuous epidural analgesia (CEA) using local anesthetics is frequently used to control herpes zoster pain and prevent postherpetic neuralgia (PHN). However, few studies have been conducted to determine the efficacy of epidural drugs administered as CEA to manage PHN. This retrospective study was designed to evaluate the effectiveness of CEA with ropivacaine alone or with ropivacaine and fentanyl for controlling pain caused by PHN.We reviewed the medical records of 71 patients. We studied 2 groups: epidural ropivacaine (ER; CEA with ropivacaine alone; n = 44) and epidural ropivacaine and fentanyl (Epidural ropivacaine and fentanyl (ERF); CEA with ropivacaine and fentanyl; n = 27). To evaluate pain, a numeric rating scale (NRS) was evaluated at 6 time points: immediately before the procedure (baseline NRS score); 1 hour after the procedure; 14 days after the procedure; and 1, 3, and 6 months after the procedure. Complication rates were recorded during CEA. We also investigated whether additional invasive procedures were needed due to insufficient pain control during the 6-month follow-up period.After adjusting for confounding variables, there were no significant differences in the NRS scores between the 2 groups at any time point. The adjusted odds ratio for additional invasive procedures within 6 months after CEA was 1.03-times higher in the ERF group than in the ER group, but this difference was not statistically significant (95% confidence interval: 0.33-3.23, P = .96). Rates of complication (dysuria, vomiting, nausea, itching sensation, and hypotension) during CEA were higher in the ERF group than in the ER group. However, the differences were not statistically significant.There was no difference in the management of pain in patients with PHN between the groups. Epidural administration of fentanyl with ropivacaine did not improve pain management when compared to ropivacaine alone. Although not statistically significant, the incidence of complications during CEA was higher in the opioid combination group.


Assuntos
Analgesia Epidural/métodos , Anestésicos Intravenosos/uso terapêutico , Anestésicos Locais/uso terapêutico , Fentanila/uso terapêutico , Neuralgia Pós-Herpética/tratamento farmacológico , Ropivacaina/uso terapêutico , Idoso , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Quimioterapia Combinada , Feminino , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Ropivacaina/administração & dosagem , Ropivacaina/efeitos adversos
18.
Rev. Soc. Esp. Dolor ; 27(3): 221-226, mayo-jun. 2020. ilus
Artigo em Espanhol | IBECS | ID: ibc-196769

RESUMO

INTRODUCCIÓN: La neuralgia occipital es una entidad con componentes bien definidos, pero ocasionalmente subdiagnosticada, que tiende a mantener un comportamiento insidioso y generar cierta resistencia al tratamiento médico, manteniendo una buena respuesta al manejo intervencionista con un mínimo índice de complicaciones asociadas y un alivio del dolor satisfactorio y prolongado. DESCRIPCIÓN DEL CASO: Presentamos 5 casos de pacientes con criterios definidos para neuralgia occipital por la (IHS), los cuales fueron manejados mediante descompresión suboccipital percutánea, evaluados por la escala numérica análoga y escala verbal análoga durante un periodo de 90 días. Los procedimientos se realizaron sin complicaciones ni eventos adversos. El resultado fue un alivio satisfactorio para el paciente del dolor crónico, con una adecuada especificidad del sitio del padecimiento, así como mejoría en la calidad de vida, el estado de ánimo, el consumo de medicamentos y la satisfacción de la paciente. CONCLUSIONES: Consideramos que el uso de la descompresión percutánea del nervio occipital mayor vía suboccipital puede ser tomada como una alternativa en pacientes con neuralgia occipital, con una alta probabilidad de obtener un beneficio analgésico y una baja probabilidad de presentar algún efecto adverso o complicación


INTRODUCTION: Occipital neuralgia is an entity with welldefined components, but occasionally underdiagnosed that tends to maintain insidious behavior and generate some resistance to medical treatment, maintaining a good response to interventional management with a minimum rate of associated complications and pain relief. Satisfactory and prolonged. CASE DESCRIPTION: We present 5 cases of patients with defined criteria for occipital neuralgia by (IHS) which were managed by suboccipital decompression, evaluated by the analog numerical scale and analogous verbal scale over a period of 90 days. The procedures were performed without complications or adverse events. The result was a satisfactory relief for the patient of chronic pain, with adequate specificity of the site of the condition; as well as improvement in the quality of life, mood, medication consumption and patient satisfaction. CONCLUSIONS: We consider that the use of decompression of the major occipital nerve via suboccipital route can be taken as an alternative in patients with occipital neuralgia, with a high probability of obtaining an analgesic benefit and a low probability of presenting some adverse effect or complication


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Neuralgia/terapia , Descompressão/métodos , Bupivacaína/administração & dosagem , Midazolam/administração & dosagem , Fentanila/administração & dosagem , Síndrome Pós-Laminectomia/complicações , Nervos Cranianos , Manejo da Dor/métodos , Anestesia Local/métodos , Resultado do Tratamento
19.
Am J Health Syst Pharm ; 77(Supplement_2): S41-S45, 2020 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-32426835

RESUMO

PURPOSE: To address the intravenous (i.v.) opioid shortage, computer-based alerts and modifications were implemented over 2 phases beginning in August 2017 and February 2018, respectively. A study was conducted to assess the impact of these interventions on dispenses of intermittent doses of i.v. opioids during a national shortage. METHODS: A retrospective, single-center, pre- and postimplementation study was conducted to compare opioid dispenses from September 2017 through December 2017 (phase 1) and March 2018 through May 2018 (phase 2) with dispenses during the same time periods of the previous year (historical control periods). Dispense data for intermittent doses of i.v. fentanyl, hydromorphone, and morphine and select oral opioids were collected from automated dispensing cabinets (ADCs) located in nonprocedural areas. The primary endpoint was the percentage of total intermittent doses of i.v. and oral opioids that were dispensed for i.v. administration. A subanalysis accounting for unit type was conducted. Key secondary endpoints were the numbers of oral and i.v. opioid dispenses by month. RESULTS: The final analysis included data from 92 ADCs. The percentage of i.v. opioid dispenses significantly decreased, by 9.8% during phase 1 (P < 0.0001) and by 16.8% during phase 2 (P < 0.0001) compared to dispenses during the historical control periods. These decreases were significant across all unit types except pediatric units during phase 1. Average monthly dispenses of i.v. opioids were 49.9% and 74.2% fewer than dispenses during the historical control periods after the phase 1 and phase 2 implementations, respectively. CONCLUSION: Order entry alerts and modifications significantly decreased dispenses of intermittent doses of i.v. opioids during a national shortage, with demonstrated sustainability of decreases over 7 months.


Assuntos
Analgésicos Opioides/administração & dosagem , Sistemas de Registro de Ordens Médicas , Padrões de Prática Médica/estatística & dados numéricos , Administração Intravenosa , Administração Oral , Analgésicos Opioides/provisão & distribuição , Relação Dose-Resposta a Droga , Fentanila/administração & dosagem , Humanos , Hidromorfona/administração & dosagem , Morfina/administração & dosagem , Estudos Retrospectivos
20.
Medicine (Baltimore) ; 99(20): e20001, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443302

RESUMO

Elderly patients with femoral fractures are anticipated to endure the most pain caused by positional changes required for spinal anesthesia. To improve pain relief, we compared the analgesic effects of intravenous dexmedetomidine-ketamine and dexmedetomidine-fentanyl combinations to facilitate patient positioning for spinal anesthesia in elderly patients with proximal femoral fractures. Forty-six patients were randomly assigned to two groups and received either 1 mg/kg of intravenous ketamine (group K) or 1 µg/kg of intravenous fentanyl (group F) concomitant with a loading dose of dexmedetomidine 1 µg/kg over 10 minutes, then dexmedetomidine infusion only was continued at 0.6 µg/kg/h for following 20 minutes, and titrated at a rate of 0.2 to 0.6 µg/kg/h until the end of surgery. After completion of the infusion of either ketamine or fentanyl, the patients were placed in the lateral position with the fracture site up. The pain score (0 = calm, 1 = facial grimacing, 2 = moaning, 3 = screaming, and 4 = unable to proceed because of restlessness or agitation) was used to describe the pain intensity in each step during the procedure (lateral positioning, hip flexion, and lumbar puncture), and quality score (0 = poor hip flexion, 1 = satisfactory hip flexion, 2 = good hip flexion, and 3 = optimal hip flexion) was used to describe the quality of posture. Group K showed a median pain score of 0 (0-1), 0 (0-0) and 0 (0-0) in lateral positioning, hip flexion and lumbar puncture, respectively, while group F showed a score of 3 (2.75-3), 3 (2-3) and 0 (0-1), respectively. The pain score in lateral positioning (P < .0001) and hip flexion (P < .0001) was significantly lower in group K than group F. Group K showed the significantly higher quality scores of spinal anesthesia positioning (P = .0044) than group F. Hemodynamic adverse effects, such as bradycardia, hypotension, and desaturation, were not significantly different between the groups. The administration of dexmedetomidine-ketamine showed a greater advantage in reducing pain intensity and increasing the quality with patient positioning during spinal anesthesia in elderly patients with proximal femoral fractures, without any serious adverse effects.


Assuntos
Analgesia/métodos , Analgésicos/administração & dosagem , Raquianestesia , Fraturas do Quadril/cirurgia , Posicionamento do Paciente , Idoso , Idoso de 80 Anos ou mais , Dexmedetomidina/administração & dosagem , Método Duplo-Cego , Feminino , Fentanila/administração & dosagem , Humanos , Ketamina/administração & dosagem , Masculino
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