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1.
Curr Opin Anaesthesiol ; 33(6): 746-752, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33002959

RESUMO

PURPOSE OF REVIEW: General anesthesia is a popular choice for ambulatory surgery. Spinal anesthesia is often avoided because of perceived delays due to time required to administer it and prolonged onset, as well as concerns of delayed offset, which may delay recovery and discharge home. However, the reports of improved outcomes in hospitalized patients undergoing total joint arthroplasty have renewed the interest in spinal anesthesia. This review article critically assesses the role of spinal anesthesia in comparison with fast-track general anesthesia for the outpatient setting. RECENT FINDINGS: The purported benefits of spinal anesthesia include avoidance of airway manipulation and the adverse effects of drugs used to provide general anesthesia, improved postoperative pain, and reduced postoperative opioid requirements. Improved postoperative outcomes after spinal anesthesia in hospitalized patients may not apply to the outpatient population that tends to be relatively healthier. Also, it is unclear if spinal anesthesia is superior to fast-track general anesthesia techniques, which includes avoidance of benzodiazepine premedication, avoidance of deep anesthesia, use of an opioid-sparing approach, and minimization of neuromuscular blocking agents with appropriate reversal of residual paralysis. SUMMARY: The benefits of spinal anesthesia in the outpatient setting remain questionable at best. Further studies should seek clarification of these goals and outcomes.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Analgésicos Opioides , Raquianestesia/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Ambulatórios/tendências , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Anestesia Geral/efeitos adversos , Raquianestesia/tendências , Humanos
2.
Anesthesiology ; 133(4): 801-811, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32852904

RESUMO

BACKGROUND: Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty. METHODS: This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions. RESULTS: Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness. CONCLUSIONS: Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.


Assuntos
Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Deambulação Precoce/métodos , Mepivacaína/administração & dosagem , Cuidados Pós-Operatórios/métodos , Idoso , Raquianestesia/tendências , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/tendências , Deambulação Precoce/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/tendências
3.
Pain Physician ; 23(2): 111-126, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32214288

RESUMO

BACKGROUND: With increasing costs of health care in the United States, attention is focused on expensive conditions. Musculoskeletal disorders with low back and neck pain account for the third highest amount of various disease categories. Minimally invasive interventional techniques for managing spinal pain, including epidural injections, have been considered to be growing rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis procedures. OBJECTIVES: The objectives of this analysis of epidural procedures from 2000 to 2018 are to provide an update on utilization of epidural injections in managing chronic pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018. STUDY DESIGN: Utilization patterns and variables of epidural injections in managing chronic spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the United States. METHODS: This analysis was performed by utilizing master data from CMS, physician/supplier procedure summary from 2000 to 2018. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However, from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections, 1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal epidurals, and 3.5% for cervical and thoracic interlaminar epidurals. LIMITATIONS: This analysis was limited by noninclusion of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. In addition, utilization data for individual states continues to be sparse and may not be accurate or representative of the population. CONCLUSIONS: The declining utilization of epidural injections in all categories with an annual of 2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3% and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural injections. KEY WORDS: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns.


Assuntos
Anestesia Epidural/tendências , Raquianestesia/tendências , Dor Crônica/terapia , Medicare/tendências , Manejo da Dor/tendências , Idoso , Idoso de 80 Anos ou mais , Anestesia Epidural/métodos , Raquianestesia/métodos , Dor Crônica/tratamento farmacológico , Feminino , Humanos , Injeções Epidurais/métodos , Injeções Epidurais/tendências , Região Lombossacral , Masculino , Manejo da Dor/métodos , Estados Unidos/epidemiologia
4.
Pain Physician ; 23(2): E133-E149, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32214289

RESUMO

BACKGROUND: Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009. OBJECTIVES: The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018. STUDY DESIGN: The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States. METHODS: Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. RESULTS: Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018. LIMITATIONS: This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate. CONCLUSIONS: Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%. KEY WORDS: Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.


Assuntos
Denervação/tendências , Medicare/tendências , Bloqueio Nervoso/tendências , Manejo da Dor/tendências , Doenças da Coluna Vertebral/terapia , Articulação Zigapofisária , Idoso , Idoso de 80 Anos ou mais , Anestesia por Condução/métodos , Anestesia por Condução/tendências , Raquianestesia/métodos , Raquianestesia/tendências , Dor Crônica/epidemiologia , Estudos de Coortes , Denervação/métodos , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Bloqueio Nervoso/métodos , Procedimentos Neurocirúrgicos/tendências , Dor/epidemiologia , Manejo da Dor/métodos , Estudos Retrospectivos , Doenças da Coluna Vertebral/epidemiologia , Estados Unidos/epidemiologia , Articulação Zigapofisária/cirurgia
6.
Adv Ther ; 37(1): 527-540, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31828612

RESUMO

INTRODUCTION: Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. METHODS: This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. RESULTS: Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p < 0.001). The overall success rate of spinal anesthesia was 91.6%, and no significant difference was observed between chloroprocaine, prilocaine, and bupivacaine. The patients' global satisfaction with anesthesia and surgery was over 90% in both study arms. CONCLUSIONS: Patient's choice, patient fear of the alternative technique, patient stress/anxiety, the expected ease of recovery, and the efficacy of the technique were identified as the main factors influencing patient choice of short-acting local anesthesia or general anesthesia. Spinal anesthesia with short-acting local anesthetics was preferred to general anesthesia in ambulatory surgeries and was associated with a high degree of patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02529501. Registered on June 23, 2015. Date of enrollment of the first participant July 21, 2015.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia Geral/tendências , Raquianestesia/tendências , Satisfação do Paciente/estatística & dados numéricos , Adulto , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procaína/análogos & derivados , Procaína/uso terapêutico , Estudos Prospectivos , Fatores de Tempo
7.
BMC Anesthesiol ; 19(1): 54, 2019 04 11.
Artigo em Inglês | MEDLINE | ID: mdl-30975081

RESUMO

BACKGROUND: Spinal epidural hematoma is a rare but serious complication of epidural anaesthesia and neurological impairment. Epidural hematoma usually becomes evident within a few hours of the procedure. Delayed clinical presentation of spinal epidural hematoma is even rarer and insidious. CASE PRESENTATION: We reported a case of a 44-year-old woman who underwent a caesarean section for a twin pregnancy during which a delayed dorsal spinal epidural hematoma occurred. Symptoms were reported 5 days after surgery and 72 h after removal of the epidural catheter. An MRI scan showed a dorsal epidural hematoma. The patient was moved to the Neurosurgical Department and underwent decompression surgery. CONCLUSION: The possibility of the delayed onset of a spinal epidural hematoma in a pregnant woman who undergoes epidural anaesthesia in labour must always be taken into consideration. In order to achieve the best clinical result, we stress the importance of a timely diagnosis and prompt surgical treatment.


Assuntos
Anestesia Epidural/efeitos adversos , Raquianestesia/efeitos adversos , Hematoma Epidural Espinal/diagnóstico por imagem , Transtornos Puerperais/diagnóstico por imagem , Adulto , Anestesia Epidural/tendências , Raquianestesia/tendências , Cesárea/efeitos adversos , Cesárea/tendências , Diagnóstico Diferencial , Quimioterapia Combinada , Feminino , Hematoma Epidural Espinal/etiologia , Hematoma Epidural Espinal/cirurgia , Humanos , Período Pós-Parto/fisiologia , Gravidez , Transtornos Puerperais/etiologia , Transtornos Puerperais/cirurgia
8.
BMC Anesthesiol ; 18(1): 179, 2018 11 30.
Artigo em Inglês | MEDLINE | ID: mdl-30501612

RESUMO

BACKGROUND: Regional anesthesia could affect the homeostatic system functions resulting frequently in perioperative hypothermia and consequently shivering. The objective of this trial was to evaluate the efficacy of dexmedetomidine and ondansetron to reduce the incidence and severity of shivering after intrathecal blocks. METHODS: This randomized placebo-controlled trial included 120 patients allocated equally in three groups. All patients were anesthetized by standard intrathecal blocks for surgical procedure at lower half of the body and received one of the study drugs intravenously (IV) according to the group assignments. Group S patients (placebo) were administered saline, Group O (ondansetron) were given 8 mg ondansetron, and Group D (dexmedetomidine) were given 1 µg/kg of dexmedetomidine. Shivering incidence and scores, sedation scores, core body temperature, hemodynamic variables, and incidence of complications (nausea, vomiting, hypotension, bradycardia, over-sedation, and desaturation) were recorded. RESULTS: The incidence and 95% confidence interval (95% CI) of shivering in group S 57.5% (42.18-72.82%) was significantly higher than that of both group O 17.5% (5.73-29.27%), P < 0.001 and group D 27.5% (13.66-41.34%), P = 0.012. However, the difference in the incidence of shivering between group O and group D was comparable, P = 0.425. The sedation scores were significantly higher in group D than those of both group S and group O, P < 0.001. Sedation scores between group S and group O were comparable, P = 0.19. Incidences of adverse effects were comparable between the three groups. CONCLUSION: Prophylactic administrations of dexmedetomidine or ondansetron efficiently decrease the incidence and severity of shivering after spinal anesthesia as compared to placebo without significant difference between their efficacies when compared to each other. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR) under trial number (PACTR201710002706318). 18-10-2017. 'retrospectively registered'.


Assuntos
Raquianestesia/efeitos adversos , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Ondansetron/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Tremor por Sensação de Frio/efeitos dos fármacos , Adulto , Raquianestesia/tendências , Antieméticos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Feminino , Frequência Cardíaca/efeitos dos fármacos , Frequência Cardíaca/fisiologia , Humanos , Masculino , Projetos Piloto , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Tremor por Sensação de Frio/fisiologia
9.
BMC Musculoskelet Disord ; 19(1): 249, 2018 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-30037342

RESUMO

BACKGROUND: The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary unicompartmental knee arthroplasty (UKA). METHODS: Between January 2016 until August 2016, 134 patients underwent primary UKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 38) or epidural catheter (group SP&EPI, n = 20) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 46) or spinal anesthesia (group SP&LIA, n = 30). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: The LIA groups revealed significantly lower (about 50%) mean NRS scores (at rest) compared to the catheter-based groups at the day of surgery. In the early postoperative period, the dose of hydromorphone as rescue pain medication was significantly lower (up to 68%) in patients with SP&EPI compared to all other groups. No significant differences could be detected with regard to grade of mobilization, muscle strength and range of motion. However, there seemed to be a trend towards improved mobilization and muscle strength with general anesthesia and LIA, whereof general anesthesia generally tended to ameliorate mobilization. CONCLUSIONS: Except for a significant lower NRS score at rest in the LIA groups at day of surgery, pain relief was comparable in all groups without clinically relevant differences, while the use of opioids was significantly lower in patients with SP&EPI. A clear clinically relevant benefit for LIA in UKA cannot be stated. However, LIA offers a safe and effective treatment option comparable to the well-established conventional procedures.


Assuntos
Anestesia Geral/tendências , Anestesia Local/tendências , Raquianestesia/tendências , Artroplastia do Joelho/tendências , Bloqueio Nervoso Autônomo/tendências , Recuperação de Função Fisiológica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/métodos , Anestesia Local/métodos , Raquianestesia/métodos , Anestésicos Locais/administração & dosagem , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Bloqueio Nervoso Autônomo/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/cirurgia , Manejo da Dor/métodos , Manejo da Dor/tendências , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controle , Recuperação de Função Fisiológica/efeitos dos fármacos , Estudos Retrospectivos , Resultado do Tratamento
10.
BMC Musculoskelet Disord ; 19(1): 232, 2018 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-30021587

RESUMO

BACKGROUND: Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. METHODS: Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS: Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8.4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. CONCLUSIONS: The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups.


Assuntos
Anestesia Geral/tendências , Anestesia Local/tendências , Raquianestesia/tendências , Artroplastia do Joelho/tendências , Bloqueio Nervoso Autônomo/tendências , Manejo da Dor/tendências , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/métodos , Anestesia Local/métodos , Raquianestesia/métodos , Artroplastia do Joelho/métodos , Bloqueio Nervoso Autônomo/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Dor Pós-Operatória/diagnóstico por imagem , Dor Pós-Operatória/prevenção & controle , Amplitude de Movimento Articular/efeitos dos fármacos , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica/efeitos dos fármacos , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Resultado do Tratamento
11.
Anesth Analg ; 127(3): 759-766, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29847387

RESUMO

BACKGROUND: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks). METHODS: All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1-3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm-Bonferroni step-down procedure. RESULTS: General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2-75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0-3.2]; P < .001). Other secondary outcomes (including opioid use, opioid side effects, nausea, headache, sore throat, and back pain) were not different. CONCLUSIONS: General anesthesia was associated with earlier readiness for discharge, but the difference may not be clinically significant and did not lead to earlier actual discharge. Most secondary outcomes were not different between groups. The choice of spinal or general anesthesia as an adjunct to peripheral nerve blockade can reflect patient, clinician, and institutional preferences.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/tendências , Anestesia Geral/tendências , Raquianestesia/tendências , Bloqueio Nervoso Autônomo/tendências , Pé/cirurgia , Alta do Paciente/tendências , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia Geral/métodos , Raquianestesia/métodos , Bloqueio Nervoso Autônomo/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Medição da Dor/tendências , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/prevenção & controle , Fatores de Tempo
12.
Anesth Analg ; 125(6): 1907-1910, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28991112

RESUMO

To investigate the influence of age on sensitivity to dexmedetomidine sedation in adult patients, we selected 79 patients scheduled for lower limb orthopedic surgery under spinal anesthesia to identify the dexmedetomidine ED50 for adequate sedation among different age groups. After a spinal anesthetic was placed, a dose of dexmedetomidine determined by the Dixon up-and-down method was administered over 15 minutes. The ED50 in the elderly group was lower than in the other 2 groups (elderly: 0.88 ± 0.07; middle aged: 1.16 ± 0.08; young: 1.21 ± 0.06 µg/kg; both P < .001). There was no difference between the young and middle-aged groups (P = .160).


Assuntos
Envelhecimento/efeitos dos fármacos , Raquianestesia/tendências , Dexmedetomidina/farmacologia , Hipnóticos e Sedativos/farmacologia , Extremidade Inferior/cirurgia , Procedimentos Ortopédicos/tendências , Adolescente , Adulto , Idoso , Envelhecimento/fisiologia , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
13.
Anesth Analg ; 123(5): 1325-1327, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27636740

RESUMO

Dilation of lymphatic vessels may contribute to iatrogenic dissemination of cancer cells during surgery. We sought to determine whether neuraxial anesthesia reduces regional lymphatic flow. Using nuclear lymphoscintigraphy, 5 participants receiving spinal anesthesia for brachytherapy had lower extremity lymph flow at rest compared with flow under conditions of spinal anesthesia. Six limbs were analyzed. Four limbs were excluded because of failure to demonstrate lymph flow (1 patient, 2 limbs), colloid injection error (1 limb), and undiagnosed deep vein thrombosis (1 limb). All analyzed limbs showed reduced lymph flow washout from the pedal injection site (range 62%-100%) due to neuraxial anesthesia. Lymph flow was abolished in 3 limbs. We report proof-of-concept that neuraxial anesthesia reduces lymphatic flow through a likely mechanism of sympathectomy.


Assuntos
Raquianestesia/tendências , Linfa/fisiologia , Linfocintigrafia/métodos , Raquianestesia/efeitos adversos , Braquiterapia/métodos , Feminino , Humanos , Extremidade Inferior/fisiologia , Linfa/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade
14.
Eur Rev Med Pharmacol Sci ; 19(20): 3886-94, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26531275

RESUMO

OBJECTIVE: Serum Brain-Derived Neurotrophic Factor (BDNF) levels are associated with neurotransmission and cognitive functions. The goal of this study was to examine the effect of general anesthesia on BDNF levels. It was also to reveal whether this effect had a relationship with the surgical stress response or not. PATIENTS AND METHODS: The study included 50 male patients, age 20-40, who were scheduled to have inguinoscrotal surgery, and who were in the ASA I-II risk group. The patients were divided into two groups according to the anesthesia techniques used: general (GA) and spinal (SA). In order to measure serum BDNF, cortisol, insulin and glucose levels, blood samples were taken at four different times: before and after anesthesia, end of the surgery, and before transferal from the recovery room. RESULTS: Serum BDNF levels were significantly low (p < 0.01), cortisol and glucose levels were higher (p < 0.05 and p < 0.01) in Group GA compared with Group SA. No significant difference was detected between the groups in terms of serum insulin levels. There was no correlation between serum BDNF and the stress hormones. CONCLUSIONS: Our findings suggested that general anesthetics had an effect on serum BDNF levels independent of the stress response. In future, BDNF could be used as biochemical parameters of anesthesia levels, but studies with a greater scope should be carried out to present the relationship between anesthesia and neurotrophins.


Assuntos
Anestesia Geral/métodos , Raquianestesia/métodos , Fator Neurotrófico Derivado do Encéfalo/sangue , Adulto , Anestesia Geral/tendências , Raquianestesia/tendências , Biomarcadores/sangue , Humanos , Hidrocortisona/sangue , Insulina/sangue , Masculino , Estudos Prospectivos , Adulto Jovem
15.
BMC Anesthesiol ; 15: 141, 2015 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-26450424

RESUMO

BACKGROUND: Little is known about the changes in autonomic function during spinal anaesthesia in type 2 diabetic patients. The purpose of the study was to assess the influence of spinal anaesthesia on the heart rate variability in type 2 diabetic patients according to the glycated hemoglobin (HbA1c) level. METHODS: Sixty-six patients who were scheduled for elective orthostatic lower limb surgery were assigned to three groups (n = 22, each) according to HbA1c; controlled diabetes mellitus (HbA1c < 7 %), uncontrolled diabetes mellitus (HbA1c > 7 %) and the control group. The heart rate variability was measured 10 min before (T0), and at10 min (T1), 20 min (T2) and 30 min (T3) after spinal anaesthesia. RESULTS: Before spinal anaesthesia, total, low-and high-frequency power were significantly lower in the uncontrolled diabetec group than in other group (p < 0.05). During spinal anaesthesia, total, low- and high-frequency powers were did not change in the uncontrolled diabetec group while the low-frequency power in the controlled diabetec group was significantly depressed (p < 0.05). The ratio of low-to high-frequency was comparable among the groups, while it was reduced at T1-2 than at T0 in all the groups. The blood pressures were higher in the uncontrolled diabetec group than in the other groups. CONCLUSIONS: Spinal anaesthesia had an influence on the cardiac autonomic modulation in controlled diabetec patients, but not in uncontrolled diabetec patients. There were no differences in all haemodynamic variables during an adequate level of spinal anaesthesia in controlled and uncontrolled type 2 DM. TRIAL REGISTRATION: ClinicalTrials.gov NCT02137057.


Assuntos
Raquianestesia/tendências , Diabetes Mellitus Tipo 2/fisiopatologia , Frequência Cardíaca/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Raquianestesia/efeitos adversos , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/cirurgia , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
16.
Anesthesiology ; 123(1): 55-65, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26001028

RESUMO

BACKGROUND: Awake regional anesthesia (RA) is a viable alternative to general anesthesia (GA) for infants undergoing lower abdominal surgery. Benefits include lower incidence of postoperative apnea and avoidance of anesthetic agents that may increase neuroapoptosis and worsen neurocognitive outcomes. The General Anesthesia compared to Spinal anesthesia study compares neurodevelopmental outcomes after awake RA or GA in otherwise healthy infants. The aim of the study is to describe success and failure rates of RA and report factors associated with failure. METHODS: This was a nested cohort study within a prospective, randomized, controlled, observer-blind, equivalence trial. Seven hundred twenty-two infants 60 weeks or less postmenstrual age scheduled for herniorrhaphy under anesthesia were randomly assigned to receive RA (spinal, caudal epidural, or combined spinal caudal anesthetic) or GA with sevoflurane. The data of 339 infants, where spinal or combined spinal caudal anesthetic was attempted, were analyzed. Possible predictors of failure were assessed including patient factors, technique, experience of site and anesthetist, and type of local anesthetic. RESULTS: RA was sufficient for the completion of surgery in 83.2% of patients. Spinal anesthesia was successful in 86.9% of cases and combined spinal caudal anesthetic in 76.1%. Thirty-four patients required conversion to GA, and an additional 23 patients (6.8%) required brief sedation. Bloody tap on the first attempt at lumbar puncture was the only risk factor significantly associated with block failure (odds ratio = 2.46). CONCLUSIONS: The failure rate of spinal anesthesia was low. Variability in application of combined spinal caudal anesthetic limited attempts to compare the success of this technique to spinal alone.


Assuntos
Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Apneia/diagnóstico , Desenvolvimento Infantil/efeitos dos fármacos , Hérnia Inguinal/cirurgia , Anestesia por Condução/efeitos adversos , Anestesia por Condução/tendências , Anestesia Geral/tendências , Raquianestesia/tendências , Apneia/etiologia , Estudos de Coortes , Feminino , Hérnia Inguinal/diagnóstico , Humanos , Lactente , Recém-Nascido , Internacionalidade , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Método Simples-Cego , Falha de Tratamento , Resultado do Tratamento
17.
Anesthesiology ; 123(1): 38-54, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26001033

RESUMO

BACKGROUND: Postoperative apnea is a complication in young infants. Awake regional anesthesia (RA) may reduce the risk; however, the evidence is weak. The General Anesthesia compared to Spinal anesthesia study is a randomized, controlled trial designed to assess the influence of general anesthesia (GA) on neurodevelopment. A secondary aim is to compare rates of apnea after anesthesia. METHODS: Infants aged 60 weeks or younger, postmenstrual age scheduled for inguinal herniorrhaphy, were randomized to RA or GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born less than 26 weeks gestation. The primary outcome of this analysis was any observed apnea up to 12 h postoperatively. Apnea assessment was unblinded. RESULTS: Three hundred sixty-three patients were assigned to RA and 359 to GA. Overall, the incidence of apnea (0 to 12 h) was similar between arms (3% in RA and 4% in GA arms; odds ratio [OR], 0.63; 95% CI, 0.31 to 1.30, P = 0.2133); however, the incidence of early apnea (0 to 30 min) was lower in the RA arm (1 vs. 3%; OR, 0.20; 95% CI, 0.05 to 0.91; P = 0.0367). The incidence of late apnea (30 min to 12 h) was 2% in both RA and GA arms (OR, 1.17; 95% CI, 0.41 to 3.33; P = 0.7688). The strongest predictor of apnea was prematurity (OR, 21.87; 95% CI, 4.38 to 109.24), and 96% of infants with apnea were premature. CONCLUSIONS: RA in infants undergoing inguinal herniorrhaphy reduces apnea in the early postoperative period. Cardiorespiratory monitoring should be used for all ex-premature infants.


Assuntos
Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Apneia/diagnóstico , Desenvolvimento Infantil/efeitos dos fármacos , Complicações Pós-Operatórias/diagnóstico , Vigília , Anestesia Geral/tendências , Raquianestesia/tendências , Apneia/etiologia , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Internacionalidade , Masculino , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Resultado do Tratamento
18.
Curr Opin Anaesthesiol ; 28(3): 333-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25915202

RESUMO

PURPOSE OF REVIEW: Spinal anesthesia has long been described as a well-tolerated and effective means of providing anesthesia for infants undergoing lower abdominal surgery. Now, spinal anesthetics are being used for an increasing variety of surgeries previously believed to require a general anesthetic. This, along with increasing concerns over the neurocognitive effects of general anesthetics on developing brains, suggests that further exploration into this technique and its effects is essential. RECENT FINDINGS: Exposure to spinal anesthesia in infancy has not shown the same suggestions of neurocognitive detriment as those resulting from general anesthesia. Ultrasound guidance has enhanced spinal technique by providing real-time guidance into the intrathecal space and confirming medication administration location, as well as helping avoid adverse outcomes by identifying aberrant anatomy. Spinal anesthesia provides benefits over general anesthesia, including cardiorespiratory stability, shorter postoperative recovery, and faster return of gastrointestinal function. SUMMARY: Early findings of spinal anesthesia exposure in infancy have shown it to have no independent effect on neurocognitive delay as well as to provide sound cardiorespiratory stability. With safer means of administering a spinal anesthetic, such as with ultrasound guidance, it is a readily available and desirable tool for those providing anesthesia to infants.


Assuntos
Raquianestesia/métodos , Adolescente , Raquianestesia/efeitos adversos , Raquianestesia/psicologia , Raquianestesia/tendências , Criança , Pré-Escolar , Cognição , Humanos , Lactente , Recém-Nascido , Complicações Pós-Operatórias/psicologia , Ultrassonografia de Intervenção
19.
Anesthesiology ; 122(4): 736-45, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25635593

RESUMO

BACKGROUND: During spinal anesthesia for cesarean delivery, phenylephrine can cause reflexive decreases in maternal heart rate and cardiac output. Norepinephrine has weak ß-adrenergic receptor agonist activity in addition to potent α-adrenergic receptor activity and therefore may be suitable for maintaining blood pressure with less negative effects on heart rate and cardiac output compared with phenylephrine. METHODS: In a randomized, double-blinded study, 104 healthy patients having cesarean delivery under spinal anesthesia were randomized to have systolic blood pressure maintained with a computer-controlled infusion of norepinephrine 5 µg/ml or phenylephrine 100 µg/ml. The primary outcome compared was cardiac output. Blood pressure heart rate and neonatal outcome were also compared. RESULTS: Normalized cardiac output 5 min after induction was greater in the norepinephrine group versus the phenylephrine group (median 102.7% [interquartile range, 94.3 to 116.7%] versus 93.8% [85.0 to 103.1%], P = 0.004, median difference 9.8%, 95% CI of difference between medians 2.8 to 16.1%). From induction until uterine incision, for norepinephrine versus phenylephrine, systolic blood pressure and stroke volume were similar, heart rate and cardiac output were greater, systemic vascular resistance was lower, and the incidence of bradycardia was smaller. Neonatal outcome was similar between groups. CONCLUSIONS: When given by computer-controlled infusion during spinal anesthesia for cesarean delivery, norepinephrine was effective for maintaining blood pressure and was associated with greater heart rate and cardiac output compared with phenylephrine. Further work would be of interest to confirm the safety and efficacy of norepinephrine as a vasopressor in obstetric patients.


Assuntos
Raquianestesia , Pressão Sanguínea/efeitos dos fármacos , Cesárea , Monitorização Intraoperatória/métodos , Norepinefrina/administração & dosagem , Fenilefrina/administração & dosagem , Adulto , Raquianestesia/tendências , Pressão Sanguínea/fisiologia , Determinação da Pressão Arterial/métodos , Cesárea/tendências , Método Duplo-Cego , Feminino , Humanos , Gravidez
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