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1.
Ann Otol Rhinol Laryngol ; 129(1): 55-62, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31801377

RESUMO

OBJECTIVE: The purpose of this study was to describe typical anesthesia practices for children with obstructive sleep apnea (OSA). STUDY DESIGN: Online survey. METHOD: A sample of pediatric anesthesiologists received the survey by email. RESULTS: 110 respondents were included. 46.4% worked in a free-standing children's hospital and 32.7% worked in a children's facility within a general hospital. 73.6% taught residents. 44.4% saw at least one child with OSA per week, 25.5% saw them daily. On a 100-mm visual analog scale, respondents rated their comfort with managing these children as 84.94 (SD 17.59). For children with severe OSA, 53.6% gave oral midazolam preoperatively, but 24.5% typically withheld premedication and had the parent present for induction. 68.2% would typically use nitrous oxide for inhalational induction. 68.2% used fentanyl intraoperatively, while 20.0% used morphine. 61.5% reduced their intraop narcotic dose for children with OSA. 98.2% used intraoperative dexamethasone, 58.2% used 0.5 mg/kg for the dose. 98.2% used ondansetron, 62.7% used IV acetaminophen, and 8.2% used IV NSAIDs. 83.6% extubated awake. 27.3% of respondents stated that their institution had standardized guidelines for perioperative management of children with OSA undergoing adenotonsillectomy. People who worked in children's hospitals, who had >10 years of experience, or who saw children with OSA frequently were significantly more comfortable dealing with children with OSA (P < 0.05). CONCLUSION: Apart from using intraoperative dexamethasone and ondansetron, management varied. These children would likely benefit from best practices perioperative management guidelines.


Assuntos
Analgésicos/uso terapêutico , Anestesiologia , Anestésicos/uso terapêutico , Antieméticos/uso terapêutico , Pediatria , Padrões de Prática Médica , Apneia Obstrutiva do Sono/cirurgia , Tonsilectomia , Acetaminofen/uso terapêutico , Adenoidectomia , Extubação/métodos , Anti-Inflamatórios não Esteroides/uso terapêutico , Dexametasona/uso terapêutico , Fentanila/uso terapêutico , Humanos , Midazolam/uso terapêutico , Morfina/uso terapêutico , Óxido Nitroso/uso terapêutico , Ondansetron/uso terapêutico , Guias de Prática Clínica como Assunto , Inquéritos e Questionários
2.
Am Surg ; 85(10): 1155-1158, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657314

RESUMO

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015-March 2017) and after OSMMAP implementation (April 2017-March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.


Assuntos
Analgésicos Opioides/uso terapêutico , Procedimentos Cirúrgicos do Sistema Digestório , Tolerância a Medicamentos , Morfina/uso terapêutico , Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Adulto , Analgésicos não Entorpecentes/administração & dosagem , Analgésicos não Entorpecentes/uso terapêutico , Analgésicos Opioides/administração & dosagem , Estudos de Casos e Controles , Protocolos Clínicos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Feminino , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Humanos , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Medicação Pré-Anestésica/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Resultado do Tratamento
3.
Saudi Med J ; 40(7): 687-693, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31287129

RESUMO

OBJECTIVES: To assess the insertion and ventilation of the laryngeal mask airway (LMA) classic while using different head positions with or without muscle relaxant. METHODS: This is a double-blind randomized clinical trial. Patients scheduled for ureteral calculus surgery at Shanghai General Hospital, Shanghai, China were recruited between November 2017 and November 2018. A total of 132 adults were consecutively selected. Patients were randomly divided into 4 groups according to head positioning and muscle relaxant use. An 8-cm-high pillow was used to achieve the sniffing position. The insertion time, initial peak pressure (Ppeak), mean pressure (Pmean) of the airway during intermittent positive pressure ventilation (primary endpoint) and fiberoptic score of the LMA position (secondary endpoint) were evaluated via electronic bronchoscopy through the mask bar. All adverse events were recorded. Results: Data were analyzed by ANOVA, 2-way ANOVA, Chi-squared, Cochran-Mantel-Haenszel, and Kruskal-Wallis tests. The insertion time required for the first attempt, fiberoptic score, Ppeak and Pmean did not differ among the groups. However, the incidence of adverse events in groups not using muscle relaxant was higher than in those using muscle relaxant. Conclusion: Use of a sniffing position and muscle relaxant slightly eased the insertion of the LMA but did not affect the fiberoptic score or ventilation parameters. Using a muscle relaxant, but not the sniffing position, reduced the incidence of adverse effects.


Assuntos
Anestesia Geral/métodos , Ventilação com Pressão Positiva Intermitente/métodos , Máscaras Laríngeas , Fármacos Neuromusculares Despolarizantes/uso terapêutico , Posicionamento do Paciente/métodos , Succinilcolina/uso terapêutico , Adulto , Idoso , Anestésicos Intravenosos/uso terapêutico , Broncoscopia , China , Método Duplo-Cego , Feminino , Fentanila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Propofol/uso terapêutico , Cálculos Ureterais/cirurgia , Procedimentos Cirúrgicos Urológicos , Adulto Jovem
4.
Acta Med Port ; 32(5): 388-399, 2019 May 31.
Artigo em Português | MEDLINE | ID: mdl-31166900

RESUMO

INTRODUCTION: All health professionals should be aware of the importance of evaluating pain - fifth vital sign- in cancer patients. Peripheral and central acting analgesics are widely used to treat moderate to severe pain, particularly cancer pain. Many guidelines have addressed this issue. However, real life patients' have other problems and comorbidities that may raise doubts when prescribing. MATERIAL AND METHODS: Authors made a literature search, trying to clarify same specific situations: loss of oral route, renal impairment (hemodialysis), hepatic impairment, frequent opiod interactions and the availability of short-acting formulations. RESULTS: The following medicines were included in this analysis: the natural opiates (morphine and codeine), their synthetic and semisynthetic derivatives (hydromorphone, oxycodone, and fentanyl), the partial agonist buprenorphine and finally tramadol and tapentadol. Transdermal systems are only available for buprenorphine and fentanyl. In hepatic impairment, fentanyl is safe, but with the exception of codeine and tramadol; other opioids should be used with caution. In renal failure: fentanyl, hydromorphone, and tapentadol are safe. Morphine should be avoided; other opioids should be used with caution. In hemodialysis, buprenorphine, fentanyl, hydromorphone and tramadol (at doses up to 200 mg/day) may be used. DISCUSSION: Failure to recognize the impact of various situations described throughout this work, including the bioavailability due to loss of oral route, due to pharmacokinetics and pharmacodynamics of the various drugs, either in the context of the impaired metabolism or excretion, or in due to pharmacological interactions, conditions a serious risk of subtreatment of pain and consequent impact in terms of quality of life. CONCLUSION: Opioid prescription is safe and effective, even in moderate to severe comorbidities such as renal and hepatic impairment and in patients with no oral route available. In this case, as when considering pharmacological interactions, an individualized therapeutic plan is the best solution and the patient should be assessed regularly. Unadjusted doses may relate to bad pain control and a higher prevalence of adverse events.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor do Câncer/tratamento farmacológico , Administração Oral , Analgésicos Opioides/metabolismo , Buprenorfina/uso terapêutico , Codeína/uso terapêutico , Transtornos de Deglutição/complicações , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Humanos , Hidromorfona/uso terapêutico , Falência Hepática/metabolismo , Morfina/uso terapêutico , Oxicodona/uso terapêutico , Diálise Renal , Insuficiência Renal/terapia , Tapentadol/uso terapêutico , Tramadol/uso terapêutico
5.
Support Care Cancer ; 27(10): 3639-3645, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31154533

RESUMO

Opioids are essential for the treatment of pain, which is a serious symptom for children and adolescents affected by cancer. Intranasal opioids may be very useful for the treatment of breakthrough pain in children and adolescents with cancer, for their little invasiveness, ease of administration, rapid onset of action, and high bioavailability. Intranasal drug delivery may be influenced by anatomical and physiological factors (nasal mucosa absorption area, mucociliary clearance, enzymatic activity, anatomical anomalies, chronic or inflammatory alterations of nasal mucosa), drug-related factors (molecular weight, solubility), and delivery device. Fentanyl is a lipophilic opioid commonly proposed for intranasal use among pediatric patients, but no studies have been conducted yet about intranasal use of other available opioids for management of pediatric cancer pain. In this review, we analyze several elements which may influence absorption of intranasal opioids in children and adolescents, with a focus on pharmacokinetics and therapeutic aspects of each opioid currently available for intranasal use.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Dor Irruptiva/tratamento farmacológico , Dor do Câncer/tratamento farmacológico , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Administração Intranasal , Adolescente , Criança , Sistemas de Liberação de Medicamentos , Humanos , Mucosa Nasal , Neoplasias/patologia , Medição da Dor
6.
Curr Pain Headache Rep ; 23(7): 50, 2019 Jun 21.
Artigo em Inglês | MEDLINE | ID: mdl-31227918

RESUMO

PURPOSE OF REVIEW: The administration of a transdermal fentanyl patch can be complicated with different pharmacokinetics than other fentanyl preparations. RECENT FINDINGS: The medical condition and baseline opioid requirements must all be carefully considered when dosing a fentanyl patch. An advantage of the fentanyl patch is its ability to bypass the gastrointestinal tract and in many patients, provide effective analgesia with minimal side effects. Fentanyl patches must be carefully administered since morbidity and/or mortality can result from the following: Giving higher doses than a patient needs, combining the medication with potent sedatives, or heating a fentanyl patch. The use of a transdermal fentanyl patch for the treatment of acute postoperative pain is not recommended and any patient undergoing a surgical procedure should have the fentanyl patch removed preoperatively. The current manuscript discusses the history of fentanyl and the fentanyl patch, as well as perioperative considerations, contraindications, current clinical efficacy, and clinical adversities related to the transdermal fentanyl patch. Regarding the heating of a transdermal fentanyl patch, which significantly increases blood levels of fentanyl, it is of the utmost importance that the patch be removed prior to surgery.


Assuntos
Analgésicos Opioides/administração & dosagem , Consenso , Fentanila/administração & dosagem , Dor Pós-Operatória/cirurgia , Adesivo Transdérmico , Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Humanos , Morfina/uso terapêutico , Medição da Dor , Adesivo Transdérmico/efeitos adversos , Resultado do Tratamento
7.
World Neurosurg ; 128: e709-e718, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31077891

RESUMO

OBJECTIVE: The purpose of this study was to assess the immediate postoperative clinical outcomes and perform a preliminary analysis of the effectiveness of biportal endoscopic approaches to lumbar decompressive laminectomy in the treatment of lumbar spinal stenosis. METHODS: All participants (64 patients) were randomly assigned in a 1:1 ratio to either the biportal endoscopic lumbar decompressive laminectomy (BE-D) group or the mini-open microscopic lumbar decompressive laminectomy (MI-D) group. Early postoperative outcomes were evaluated using clinical and surgical technique-related outcomes. The visual analog scale (VAS) pain score was measured at 6 time points after surgery (at 4, 8, 16, 24, and 48 hours and 2 weeks). Surgical technique-related outcomes were also analyzed. RESULTS: There were no significant differences in the preoperative demographics between the 2 groups. The VAS pain score from 8 to 48 hours (P < 0.05) was significantly lower in the BE-D group than in the MI-D group. Moreover, the total amount of fentanyl usage was higher in the MI-D group than in the BE-D group after surgery (P = 0.026). The length of hospital stay was lower in the BE-D group than in the MI-D group (P = 0.048). The operative time and creatinine phosphokinase level were not significantly different between the groups (P >0.05). Postoperative drainage was significantly higher in the BE-D group than in the MI-D group. CONCLUSIONS: BE-D was associated with rapid pain recovery, low fentanyl usage, and early discharge after surgery, but its other benefits have not yet been shown.


Assuntos
Descompressão Cirúrgica/métodos , Laminectomia/métodos , Vértebras Lombares/cirurgia , Estenose Espinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Endoscopia , Feminino , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medição da Dor , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Estenose Espinal/diagnóstico por imagem , Resultado do Tratamento
8.
Artigo em Inglês | MEDLINE | ID: mdl-31131754

RESUMO

BACKGROUND: Fentanyl is primarily an opioid agonist. It is frequently used in general anesthesia as a potent analgesic. It can be administered either orally, transdermally or systemically. Adverse effects due to opium alkaloids are usually because of a non-specific histamine release. Only in a few cases, a true allergy mechanism could be involved. Immediate reactions to opioids are most frequent than delayed reactions. In the past years, delayed reactions have increased in frequency because of the wide use of Transdermal Therapeutic System (TTS) with several opioids for its potent analgesic properties. OBJECTIVE: The objective was to study delayed reaction to fentanyl TTS and cross-reactivity with other opioids. METHODS: A 52-year-old man with a diagnosis of pancreatic cancer who began treatment for a bone metastases pain with fentanyl TTS, at a dose of 50 micrograms per hour (mcg/h) is the subject of the study. After 10-15 days of treatment, he developed an itchy papulovesicular rash in the application site of the fentanyl TTS. Afterward, eczema and superficial desquamation just on the application site of the patch were observed. He changed several times the site of application, but always developing the same symptoms in every single application. Later on, he tolerated other opioids such as oral morphine or tramadol. An allergy workout was performed. We performed Patch Tests (PT) with fentanyl at a concentration of 10% in aqua (aq) and with buprenorphine 10% aq., in order to investigate probable crossreactivity among other topical opioids. RESULTS: Readings were recorded at day 2 (D2) and day 4 (D4), with positive PT only with fentanyl at D2 (+++) and D4 (+++). We decided to perform a single-blind challenge test with buprenorphine 35 mcg/h in TTS, with a negative result. At this moment, fentanyl TTS was replaced by buprenorphine TTS, with good tolerance. CONCLUSION: We present the case of Allergic Contact Dermatitis (ACD) due to hypersensitivity to fentanyl with good tolerance to buprenorphine. Positive PT in this patient suggests a type IV hypersensitivity mechanism. Allergic reactions to opioids are frequently immediate, but delayed reactions could appear, especially when the drug is administered topically.


Assuntos
Dermatite Alérgica de Contato/diagnóstico , Hipersensibilidade a Drogas/diagnóstico , Fentanila/efeitos adversos , Hipersensibilidade Tardia/diagnóstico , Neoplasias Pancreáticas/tratamento farmacológico , Administração Cutânea , Buprenorfina/uso terapêutico , Dermatite Alérgica de Contato/tratamento farmacológico , Hipersensibilidade a Drogas/tratamento farmacológico , Substituição de Medicamentos , Tolerância a Medicamentos , Exantema , Fentanila/uso terapêutico , Humanos , Hipersensibilidade Tardia/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Neoplasias Pancreáticas/complicações , Testes Cutâneos
9.
Pharmacol Rep ; 71(3): 438-442, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31003154

RESUMO

Breakthrough pain is defined as transient aggravation of pain that arises, despite well controlled or stable baseline pain. It may be preceded by known factors or occur spontaneously. Its prevalence is high and it considerably affects patients' quality of life. Therefore, proper clinical evaluation and treatment is required. Fentanyl transmucosal formulations have become the treatment of choice for spontaneous (idiopathic) episodes because of their rapid onset of action, brief period of analgesia, and easy administration via transmucosal routes. All rapid onset fentanyl formulations show better efficacy than placebo or immediate-release opioids administered via the oral route, with an onset of analgesia within 15 min. Furthermore, most patients show considerable tolerance of these fentanyl formulations, and severe side effects that can potentially be induced by opioids are rarely observed. However, the treatment of breakthrough pain should be adjusted to suit specific patient requirements. Nevertheless, particularly in predictable bursts of pain and also in spontaneous episodes of breakthrough pain with slowly intensifying pain, immediate-release formulations of opioids may play an important role.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Irruptiva/tratamento farmacológico , Dor Irruptiva/etiologia , Fentanila/uso terapêutico , Neoplasias/complicações , Analgesia/métodos , Humanos , Medição da Dor/métodos , Qualidade de Vida
10.
Vet Anaesth Analg ; 46(3): 384-394, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30962041

RESUMO

OBJECTIVE: To design and assess the perioperative analgesic efficacy of an ultrasound (US)-guided radial (R), ulnar (U), median (M) and musculocutaneous (Mc) nerve blocks, performed together in the axillary space by a single, in-plane approach. STUDY DESIGN: Anatomical research and prospective clinical study. ANIMALS: A group of three dog cadavers and 15 client-owned dogs undergoing orthopaedic thoracic limb surgery. METHODS: Phase 1: Anatomical dissection and US study of the axillary space were performed to design the US-guided proximal RUMM block. The technique was considered successful if a total volume of 0.15 mL kg-1 new methylene blue solution completely stained the four nerves in two cadavers for ≥2 cm. Phase 2: In 15 client-owned dogs undergoing orthopaedic thoracic limb surgery, the RUMM block designed in phase 1 was performed to provide analgesia using a total volume of 0.15 mL kg-1 of ropivacaine 0.5%. The block was considered effective if the intraoperative fentanyl requirement was <1.2 mcg kg-1 hour-1 and until the postoperative pain score was [short-form Glasgow Composite Measure Pain Scale (SF-GCMPS)] ≤5/20. RESULTS: Phase1: Detection of the four nerves was always feasible in a single US-window. The axillary artery and Mc nerve were used as landmarks. In-plane needling approach was feasible in both cadavers. All the nerves were completely stained for >2 cm. No intrathoracic dye spread was found. Phase 2: In 14/15 anaesthetized dogs, mean intraoperative fentanyl requirement was 0.25 ± 0.05 mcg kg-1 hour-1. Postoperatively, all dogs had SF-GCMPS ≤5/20 up to 8 hours. CONCLUSIONS AND CLINICAL RELEVANCE: The US-guided proximal RUMM block performed at the axillary level with a single, in-plane needling approach using 0.15 mL kg-1 of ropivacaine 0.5% minimized fentanyl requirement during thoracic limb surgery, contributing to postoperative analgesia up to 8 hours after execution of the peripheral nerve block.


Assuntos
Cães/cirurgia , Bloqueio Nervoso/veterinária , Procedimentos Ortopédicos/veterinária , Ultrassonografia de Intervenção/veterinária , Analgésicos Opioides/uso terapêutico , Animais , Cadáver , Fentanila/uso terapêutico , Membro Anterior/cirurgia , Azul de Metileno/análogos & derivados , Bloqueio Nervoso/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/veterinária , Estudos Prospectivos , Ultrassonografia de Intervenção/métodos
11.
JAMA Netw Open ; 2(3): e191340, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30924899

RESUMO

Importance: Transmucosal immediate-release fentanyl (TIRF) drugs are potent, rapid-acting opioids approved to treat breakthrough pain in patients with cancer who are tolerant to other around-the-clock opioid analgesics. In March 2012, a US Food and Drug Administration-approved Risk Evaluation and Mitigation Strategy (REMS) was implemented, mandating prescribers, distributors, pharmacies, and patients to enroll in the REMS to prescribe, dispense, or receive TIRF drugs. Objective: To evaluate the association of the TIRF-REMS Access Program with TIRF prescribing. Design, Setting, and Participants: Cohort study using an interrupted time series analysis of TIRF prescriptions to Medicare Part D beneficiaries nationwide from 2010 to 2014. Data were analyzed from August 2017 through July 2018. Main Outcomes and Measures: Prescribing of TIRF per 100 000 Medicare Part D beneficiaries, overall and stratified by cancer status; percentage of TIRF prescriptions for patients without cancer, overall and by brand; and percentage of TIRF prescriptions for patients without known opioid tolerance, defined as patients prescribed at least 60 morphine milligram equivalents per day, overall and by brand. Results: There were 99 601 TIRF prescriptions written by 8619 clinicians to 10 472 patients. Most of the patients (79%) were younger than 65 years (mean [SD] age, 56 [13] years), and most (67%) did not have cancer. Implementation of TIRF-REMS was associated with a 26.7% relative level decrease in TIRF prescribing (95% CI, -33.3% to -19.4%; P < .001) but was followed by 2.0% monthly increases in prescribing (95% CI, 1.3% to 2.7%; P < .001). Sensitivity analyses that accounted for overall opioid prescribing trends were consistent with these findings. Furthermore, there were no significant changes associated with REMS implementation in the level (0.47%; 95% CI, -5.36% to 4.69%; P = .85) or trend (0.16%; 95% CI, -0.06% to 0.37%; P = .15) of the percentage of prescriptions for patients without cancer. However, a sensitivity analysis that used a broader cancer definition found implementation was associated with a 7.2% (95% CI, -13.5% to -0.48%; P = .04) level decrease in the percentage of TIRF prescriptions for patients without cancer. Lastly, the TIRF-REMS was associated with a 22.5% level decline in the percentage of TIRF prescriptions for patients without known opioid tolerance (95% CI, -36.1% to -5.95%; P = .01) followed by 1.98% monthly decreases (95% CI, -3.19% to -0.80%; P = .001). Conclusions and Relevance: Implementation of the TIRF-REMS Access Program, a restrictive drug distribution program, was associated with a temporary reduction in the rate of TIRF prescribing to Medicare Part D beneficiaries, and with a sustained decrease in the percentage of TIRF prescriptions for patients without known opioid tolerance. Implementation may have also been associated with a temporary decrease in the percentage of TIRF prescriptions for patients without cancer.


Assuntos
Analgésicos Opioides , Prescrições de Medicamentos/estatística & dados numéricos , Fentanila , Avaliação de Risco e Mitigação , Administração através da Mucosa , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Fentanila/uso terapêutico , Humanos , Análise de Séries Temporais Interrompida , Medicare , Pessoa de Meia-Idade , Estados Unidos
12.
Trials ; 20(1): 173, 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-30885242

RESUMO

BACKGROUND: A long-acting prodrug of nalbuphine, nalbuphine sebacate, has been developed for meeting the unmet medical need of long-acting analgesics. Naldebain® (nalbuphine sebacate) has been developed as a new premedication for postoperative pain management. The primary objective of this study is to determine the efficacy and safety of a single dose of intramuscular Naldebain® in patients scheduled to undergo elective laparotomy. METHODS/DESIGN: A total of 110 patients will be recruited and randomized into two treatment groups. Group 1 receives a single dose of Naldebain® intramuscularly 24 ± 12 h prior to surgery. Group 2 receives intravenous patient-controlled analgesia (PCA) with fentanyl through 48 h postsurgery. Both groups will have follow-up observations until the final visit (day of discharge, day 6-30). The primary efficacy endpoint is to assess time-specific pain intensity calculated as the area under the curve (AUC) of a visual analog scale at individual time points and by using total AUC. Safety endpoints-including incidence of treatment, emergent adverse events, and percentage of abnormality from baseline to final visit-in vital signs, laboratory tests, and injection site evaluations will also be analyzed. Statistical analyses will be performed on the data to compare the two groups. DISCUSSION: Post-laparotomy pain can have a harmful effect on patient recovery; therefore, a slow-release formulation that can cover at least 7 days of analgesic effect is required. This study will demonstrate whether a single use of Naldebain® is not less efficacious than PCA with fentanyl for pain management as a non-inferior trial. TRIAL REGISTRATION: NCT03296488 .


Assuntos
Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Nalbufina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Interpretação Estatística de Dados , Feminino , Fentanila/efeitos adversos , Humanos , Laparotomia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Nalbufina/efeitos adversos , Nalbufina/análogos & derivados , Projetos de Pesquisa
13.
BMC Palliat Care ; 18(1): 31, 2019 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-30922276

RESUMO

BACKGROUND: Opioids are prescribed in over 40% of patients with advanced cancer, but side effects occur frequently. In this study we evaluated the development and treatment of opioid induced constipation (OIC), and OIC resolving effect of methylnaltrexone for different opioid subtypes in daily clinical practice. METHODS: Patients with cancer using opioids were included in a retrospective chart analysis. Baseline characteristics, data on opioid use, laxative use, and OIC were collected. Patients with OIC who were prescribed methylnaltrexone, were included in a prospective observational trial (NCT01955213). RESULTS: Thirty-nine of 327 patients (pts) with cancer who were treated with opioids suffered from OIC (overall prevalence 12%; 95%-CI: 8-15%). The prevalence of OIC was similar in patients treated with oxycodone or fentanyl (12 of 81 pts. vs. 18 of 110 pts., RR 0.9; 95%CI 0.4-2.0). The morphine equivalent daily dose did not significantly differ between opioid subtypes (fentanyl 89 mg (IQR 60-180) vs. oxycodone 40 mg (40-80), P = 0.231). Twenty-two individual patients (7%) were admitted for OIC. Most effective laxatives in admitted patients were enemas, methylnaltrexone, or 4-l polyethylene-glycol solution. In the prospective observational study, the effect of methylnaltrexone could be evaluated in 23 patients. Eleven patients achieved the primary endpoint of ≥2 laxation responses out of the first four doses methylnaltrexone, independent of opioid subtype. CONCLUSIONS: OIC is a burdensome clinical problem independent of opioid subtype. Timely intensification of prophylactic laxative treatment, especially when opioid doses increase, may help to prevent OIC. Clinically overt OIC requires a more intensive laxative regimen with for example methylnaltrexone. TRIAL REGISTRATION: NCT01955213 .


Assuntos
Analgésicos Opioides/efeitos adversos , Constipação Intestinal/tratamento farmacológico , Idoso , Analgésicos Opioides/uso terapêutico , Constipação Intestinal/etiologia , Feminino , Fentanila/efeitos adversos , Fentanila/uso terapêutico , Humanos , Laxantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Naltrexona/análogos & derivados , Naltrexona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Oxicodona/efeitos adversos , Oxicodona/uso terapêutico , Manejo da Dor/efeitos adversos , Manejo da Dor/métodos , Estudos Prospectivos , Compostos de Amônio Quaternário/uso terapêutico , Estudos Retrospectivos , Inquéritos e Questionários
14.
Int J Clin Pract ; 73(6): e13338, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30829429

RESUMO

BACKGROUND: Moderate to severe pain is common despite the use of potent opioids during craniotomies. Non-opioid agents such as dexmedetomidine reduce undesirable opioid effects and are successfully used as primary analgesic during bariatric surgeries. This study assessed the feasibility of conducting a large randomised controlled trial comparing fentanyl with dexmedetomidine for perioperative analgesia during craniotomy. METHODS: This was a prospective single-centre randomised controlled feasibility trial. Twenty-four consenting adult patients undergoing supratentorial craniotomy at NIMHANS, Bangalore, India, were recruited after ethical approval in March and April 2018. They received either fentanyl 1 µg kg-1  h-1 (n = 12) or dexmedetomidine 0.5  µg kg-1  h-1 (n = 12) as primary intraoperative analgesic drug. Patient, anaesthesiologist, outcome assessor and data analyst were blinded to the study intervention. Our feasibility outcomes (primary) were recruitment and adherence rates. We also explored the potential efficacy of intervention and adverse events. RESULTS: We recruited 24 out of 30 eligible patients and had 100% protocol adherence, thereby demonstrating the feasibility of a larger randomised controlled trial. All 24 patients completed the study. The demographic and clinical parameters were similar between the groups. Compared between fentanyl and dexmedetomidine, there was no difference in the intraoperative fentanyl (top-up) consumption (µg), expressed as median and interquartile range: 25 (0-50) and 0 (0-50); P = 0.844; and no difference in postoperative pain at 15 and 60 minutes. Adverse events were few and similar with fentanyl and dexmedetomidine. CONCLUSIONS: A large-scale randomised controlled trial of perioperative dexmedetomidine versus fentanyl is feasible. Dexmedetomidine has the potential to be non-inferior to fentanyl for perioperative analgesia during craniotomies.


Assuntos
Analgésicos não Entorpecentes/uso terapêutico , Craniotomia , Dexmedetomidina/uso terapêutico , Fentanila/uso terapêutico , Cuidados Intraoperatórios/métodos , Dor Pós-Operatória/prevenção & controle , Adulto , Método Duplo-Cego , Esquema de Medicação , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Resultado do Tratamento
15.
J Plast Surg Hand Surg ; 53(3): 167-172, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30734629

RESUMO

PURPOSE: Nasal bone fracture reduction surgery is normally followed by nasal packing to control bleeding. Yet, patients suffer from pain and require further analgesic treatments following nasal packing and removal. This study aimed to evaluate the effect of fentanyl-soaked packing as a method of controlling pain after nasal surgeries in a prospective, randomized, double-blind controlled trial. METHODS: Sixty-five patients that have undergone closed nasal bone fracture reduction surgery were included in this study. Thirty-two patients were treated postoperatively with 50 mcg fentanyl-soaked Merocel®, a biodegradable synthetic polyurethane foams packing, and the other 33 patients were treated with saline-soaked packings. To analyze the relative nasal pain control effect of fentanyl, Numeric Rating Scale, patient satisfaction and Ramsay Sedation Scale were used. Patients were closely monitored to record relevant cardiopulmonary indicators and degree of adverse symptoms such as headache or sore throat. RESULTS: Fentanyl group had a significantly lower Numeric Rating Scale and higher patient satisfaction for most of the time periods after operation (p < .05). Symptoms of headache and sore throat were also significantly reduced. Ramsay Sedation Scale scores improved compared to the control group (p < .05). No significant differences in cardiopulmonary relevant indicators between the two experimental groups were observed (p > .05). CONCLUSION: Fentanyl-soaked packing significantly decreased postoperative pain with no observable adverse effects. Our results demonstrate that topical fentanyl application to nasal packing is an effective method of postoperative pain control after closed nasal bone fracture reduction surgery.


Assuntos
Analgésicos Opioides/uso terapêutico , Redução Fechada , Fentanila/uso terapêutico , Osso Nasal/lesões , Dor Pós-Operatória/prevenção & controle , Fraturas Cranianas/terapia , Tampões Cirúrgicos , Adulto , Método Duplo-Cego , Feminino , Formaldeído , Hemostáticos , Humanos , Masculino , Medição da Dor , Álcool de Polivinil , Estudos Prospectivos
16.
Zhonghua Jie He He Hu Xi Za Zhi ; 42(2): 106-113, 2019 Feb 12.
Artigo em Chinês | MEDLINE | ID: mdl-30704182

RESUMO

Objective: This study aimed to explore a feasible method of anesthesia for painless bronchoscopy. Methods: A total of 120 patients receiving flexible bronchoscopy in Beijing Tiantan Hospital during the period from February, 8, 2018 to May, 4, 2018, were randomly divided into 3 groups, including group A (using lidocaine for local anesthesia), group B (using lidocaine + midazolam + fentanyl), and group C (using lidocaine + propofol + sufentanil). There were 41 patients in group A, 38 in group B and 41 in group C. The changes in systolic blood pressure, diastolic blood pressure, heart rate and pulse oxygen saturation(SpO(2)) in each group were recorded in different points of time. The safety of different methods of anesthesia was observed by recording vital signs and adverse events. Moreover, the visual analogue scale (VAS) was used to observe the patient's tolerance and satisfaction of the operation. Results: The intraoperative systolic blood pressure and diastolic blood pressure in group C were significantly lower than those in group A and B (P<0.05). Six cases in group C had hypotension, 3 of whom required vasoactive drugs. The differences of SpO(2) between the 3 groups showed no statistical significance (P>0.05), while patients in group C were prone to decrease in SpO(2). Eighteen patients in group C had hypoxemia during operation. But after treated with improving ventilation, the SpO(2) of those patients could be restored to normal. Compared with those in group C, patients in group A and group B showed significant discomfort, cough, and more pharyngeal pain (P<0.05). However, there were no significant differences in the degree of cough and pain between group A and group B (P>0.05). Most patients in group C had no uncomfortable sensation during the operation (P<0.05), and the willingness to re-examination was significantly higher than that in group A and group B (P<0.05). Conclusion: Propofol combined with sufentanil could achieve better painless effect, improve patient comfort and tolerance, and reduce intraoperative memory, but was prone to causing hypoxemia and hypotension. The decline of intraoperative SpO(2) could be corrected by establishing artificial airway, while the decrease of blood pressure could be corrected by applying vasoactive drugs, which were relatively safe.


Assuntos
Broncoscopia/métodos , Fentanila/uso terapêutico , Frequência Cardíaca/fisiologia , Lidocaína/uso terapêutico , Midazolam/uso terapêutico , Propofol/uso terapêutico , Sufentanil/uso terapêutico , Anestesia , Pressão Sanguínea , Fentanila/administração & dosagem , Fentanila/efeitos adversos , Humanos , Lidocaína/administração & dosagem , Lidocaína/efeitos adversos , Midazolam/administração & dosagem , Midazolam/efeitos adversos , Oximetria , Medição da Dor , Propofol/administração & dosagem , Propofol/efeitos adversos , Sufentanil/administração & dosagem , Sufentanil/efeitos adversos
17.
Medicine (Baltimore) ; 98(7): e14445, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30762755

RESUMO

The aim of this study was to investigate the association between purinergic receptor P2X7 (P2RX7) gene rs1718125 polymorphism and analgesic effect of fentanyl after surgery among patients with lung cancer in a Chinese Han population.A total of 238 patients with lung cancer who received resection were enrolled in our study. The genotype distributions of P2RX7 rs1718125 polymorphism were detected by polymerase chain reaction and direct sequencing. Postoperative analgesia was performed by patient-controlled intravenous analgesia, and the consumption of fentanyl was recorded. The postoperative pain was measured by visual analog scale (VAS). Differences in postoperative VAS score and postoperative fentanyl consumption for analgesia in different genotype groups were analyzed by analysis of variance assay.The frequencies of GG, GA, and AA genotypes were 46.22%, 44.96%, and 8.82%, respectively. After surgery, the postoperative VAS score of GA group was significantly high in the period of analepsia after general anesthesia and at 6 hours after surgery (P = .041 and P = .030, respectively), while AA group exhibited obviously high in the period of analepsia after general anesthesia (P < .001), at postoperative 6 hours (P = .006) and 24 hours (P = .016). Moreover, the patients carrying GA and AA genotypes needed more fentanyl to control pain within 48 hours after surgery (P < .05 for all).P2RX7 gene rs1718125 polymorphism is significantly associated with postoperative pain and fentanyl consumption in patients with lung cancer.


Assuntos
Analgésicos Opioides/uso terapêutico , Fentanila/uso terapêutico , Neoplasias Pulmonares/genética , Dor Pós-Operatória/genética , Receptores Purinérgicos P2X7/genética , Idoso , Analgesia Controlada pelo Paciente/estatística & dados numéricos , Grupo com Ancestrais do Continente Asiático/genética , China , Feminino , Genótipo , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Polimorfismo de Nucleotídeo Único/genética , Fatores de Tempo
18.
Rev. Soc. Esp. Dolor ; 26(1): 31-43, ene.-feb. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-182833

RESUMO

Introducción: El fentanilo de administración transmucosa tiene características específicas que lo convierten en el fármaco adecuado para el tratamiento del dolor irruptivo oncológico (DIO). Aunque en España existe un amplio consenso sobre la idoneidad de la administración de fentanilo transmucoso para el DIO, es relevante conocer cómo los oncólogos adecuan su prescripción al paciente y cuáles son los factores determinantes de la elección de las diferentes formas farmacéuticas. Objetivos: El objetivo principal de este proyecto fue identificar y priorizar los atributos que los oncólogos médicos españoles tienen en cuenta cuando valoran las opciones de tratamiento con fentanilo transmucoso en pacientes con DIO. Métodos: Un comité científico realizó una tipificación de 14 atributos relevantes en la prescripción de fentanilo transmucoso para el DIO. Posteriormente se generó un dossier de evidencia científica comparando estos 14 atributos entre los distintos fentanilos transmucosos disponibles, que se compartió con el panel de expertos (115 oncólogos médicos). Tras una exhaustiva revisión del documento, los participantes realizaron una votación online de priorización de los atributos. Resultados: De catorce atributos analizados, siete consiguieron un consenso de ≥ 50 % de los participantes: el inicio de la acción analgésica (84 %), la adecuación del efecto del fentanilo al perfil del episodio de DIO (72 %), la facilidad de uso por los pacientes y cuidadores (69 %), la duración del efecto (58 %), la presencia de mucositis (57 %),la facilidad de titulación de la dosis óptima (57 %) y las presentaciones y dosis disponibles (59 %). Conclusiones: Los atributos más valorados fueron los relativos a la rapidez de acción del tratamiento analgésico y su adaptación al perfil del DIO, algo esperable dadas las características clínicas del episodio de DIO. Como atributos menos valorados aparecen el riesgo de abuso o conductas aberrantes y la presencia de rinitis para su administración, lo que indica que la existencia de estos factores no tiene tanta influencia en la elección del tratamiento para el abordaje del DIO. Estos resultados permitirán a los oncólogos médicos conocer qué atributos deben ser tenidos en cuenta a la hora de personalizar los tratamientos del paciente con DIO con el objetivo de mejorar la adecuación de la analgesia de rescate


Introduction: Transmucosal fentanyl has specific properties which make it ideal for the treatment of breakthrough cancer pain (BTCP). Although there is a broad consensus for the administration of transmucosal fentanyl for BTCP in Spain, there is uncertainty as to the way oncologists adjust their prescription to the patient and what are the determinants of the choice of different pharmaceutical forms. Objectives: The main objective of this study was to analyze and prioritize the attributes that Spanish oncologists consider when assessing treatment options with transmucosal fentanyl in patients with BTCP. Methods: A Scientific Committee performed a classification of 14 relevant attributes in the prescription of transmucosal fentanyl for BTCP. Subsequently, a dossier of scientific evidence was generated comparing these 14 attributes among the different available transmucosal fentanyl formulations, which was shared with the panel of experts (115 Medical Oncologists). After a thorough review of the document, the participants carried out an online vote for the prioritization of the attributes. Results: Out of fourteen attributes analyzed, seven achieved a consensus of ≥ 50 % of the participants: the start of the analgesic action (84 %), the adequacy of the effect of fentanyl to the BTCP episode (72 %), the ease of use (58 %), the presence of mucositis (57 %), the ease of titration of the optimal dose (57%), and the variety of presentations and doses available (59 %). Conclusions: The most valued attributes were those related to the speed of action of the analgesic treatment and its adaptation to the BTCP profile, something to be expected given the spontaneous, unpredictable, and transitory nature of BTCP. As less valued attributes appear the risk of abuse or aberrant behavior and the presence of rhinitis for its administration, which indicates that the existence of these factors do not influence the choice of treatment for BTCP. These results will allow medical oncologists to know what attributes should be taken into account when customizing the patient's treatment of BTCP in order to improve the adequacy of rescue analgesia


Assuntos
Humanos , Dor Irruptiva/tratamento farmacológico , Manejo da Dor/métodos , Dor do Câncer/tratamento farmacológico , Fentanila/uso terapêutico , Analgésicos Opioides/uso terapêutico , Prova Pericial/estatística & dados numéricos , Padrões de Prática Médica
19.
Aust Vet J ; 97(1-2): 33-38, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30693492

RESUMO

BACKGROUND: Studying wild animals in situ is fundamental to collecting baseline information, but generally they need to be immobilised for examination, sampling, marking and/or equipping with tracking apparatus. Capturing wild animals is inherently risky and there is a need for immobilisation methods that are safe for both the animals and researchers. METHODS: A total of 16 free-ranging swamp buffalo (Bubalus bubalis) were chemically captured by dart for the application of satellite tracking collars in tropical northern Australia; 7 animals were anesthetised with a thiafentanil-etorphine-azaperone (TEA) combination and 9 animals with a thiafentanil-azaperone (TA) combination. Anaesthesia was reversed with intravenous naltrexone. Mean dosages of etorphine and thiafentanil for animals in the TEA group were 0.01 mg/kg of each drug and mean dosage of thiafentanil for animals in the TA group was 0.02 mg/kg. Total dose per animal of azaperone and naltrexone was 80 mg and 150 mg, respectively. Anaesthetic monitoring was by physical observation of physiological variables, pulse oximetry and capnography. Blood laboratory parameters including creatine kinase (CK), aspartate transaminase (AST), serum bicarbonate and anion gap were measured. RESULTS: All subject animals recovered well from anaesthesia despite the occurrence of subclinical acidosis in some patients. There was no significant difference between the treatment groups. Conversely, chase time had an adverse effect on body temperature, irrespective of the anaesthetic combination used. CONCLUSIONS: Thiafentanil and azaperone, with or without etorphine, delivered rapid safe, effective, reversible field anaesthesia in healthy swamp buffalo.


Assuntos
Azaperona/uso terapêutico , Búfalos , Etorfina/uso terapêutico , Fentanila/análogos & derivados , Hipnóticos e Sedativos/uso terapêutico , Imobilização/veterinária , Anestesia/métodos , Anestesia/veterinária , Animais , Animais Selvagens , Austrália , Azaperona/administração & dosagem , Búfalos/sangue , Etorfina/administração & dosagem , Fentanila/administração & dosagem , Fentanila/uso terapêutico , Hipnóticos e Sedativos/administração & dosagem , Imobilização/métodos
20.
J Korean Med Sci ; 34(3): e21, 2019 Jan 21.
Artigo em Inglês | MEDLINE | ID: mdl-30662387

RESUMO

Background: To evaluate the efficacy and safety of fentanyl for sedation therapy in mechanically ventilated children. Methods: This was a double-blind, randomized controlled trial of mechanically ventilated patients between 2 months and 18 years of age. Patients were randomly divided into two groups; the control group with midazolam alone, and the combination group with both fentanyl and midazolam. The sedation level was evaluated using the Comfort Behavior Scale (CBS), and the infusion rates were adjusted according to the difference between the measured and the target CBS score. Results: Forty-four patients were recruited and randomly allocated, with 22 patients in both groups. The time ratio of cumulative hours with a difference in CBS score (measured CBS-target CBS) of ≥ 4 points (i.e., under-sedation) was lower in the combination group (median, 0.06; interquartile range [IQR], 0-0.2) than in the control group (median, 0.15; IQR, 0.04-0.29) (P < 0.001). The time ratio of cumulative hours with a difference in CBS score of ≥ 8 points (serious under-sedation) was also lower in the combination group (P < 0.001). The cumulative amount of midazolam used in the control group (0.11 mg/kg/hr; 0.07-0.14 mg/kg/hr) was greater than in the combination group (0.07 mg/kg/hr; 0.06-0.11 mg/kg/hr) (P < 0.001). Two cases of hypotension in each group were detected but coma and ileus, the major known adverse reactions to fentanyl, did not occur. Conclusion: Fentanyl combined with midazolam is safe and more effective than midazolam alone for sedation therapy in mechanically ventilated children. Trial Registration: ClinicalTrials.gov Identifier: NCT02172014.


Assuntos
Adjuvantes Anestésicos/uso terapêutico , Ansiedade/prevenção & controle , Fentanila/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Midazolam/uso terapêutico , Adjuvantes Anestésicos/efeitos adversos , Adolescente , Criança , Pré-Escolar , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Fentanila/efeitos adversos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/etiologia , Lactente , Unidades de Terapia Intensiva , Masculino , Midazolam/efeitos adversos , Respiração Artificial , Resultado do Tratamento
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