High-intensity laser for the treatment of pain: systematic review / Laser de alta intensidade para tratamento da dor: revisão sistemática

ABSTRACT BACKGROUND AND OBJECTIVES: Pain is one of the most prevalent causes of disability in the world, and the adverse effects promoted by analgesics can limit therapeutic success. In this context, laser appears as a complementary therapy that can enhance analgesia without increasing the incidence of undesirable adverse events. The aim of this study was to carry out a systematic review on the effectiveness and efficiency of high intensity laser (HIL) in the treatment of pain. CONTENTS: A systematic search was carried out in Medline, LILACS, Pubmed and PEDro, from July 2020 to August 2022. The keywords pain, chronic pain, high intensity laser and treatment were considered. The quality of selected studies was assessed using the PEDro scale. Included systematic reviews were assessed for methodological quality using the AMSTAR tool. The main measure studied was pain intensity. 227 studies were found and, based on the inclusion and exclusion criteria, 32 articles were read in full, whit one being excluded for not assessing pain. Musculoskeletal disorders corresponded to 70,96% of the assessed diseases and the visual analogue scale (VAS) was the only pain measurement tool used in 100% of the studies. Approximately 57% of the studies were of high methodological quality (PEDro=7). In 53,84% of the trials, HIL was used as a single intervention, and in 46,16% it was associated whit exercises. In 96.15% of clinical trials and 100% of systematic reviews there were positive effects of HIL on pain. CONCLUSION: HIL is an effective modality for analgesia by promoting significant pain relief, rapid recovery and improvement in patient's quality of life, in a safe way. The diversity in irradiation parameters (dose, duration, interval and number of sessions) used, indicates the need for further randomized studies to establish its long-term efficiency.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor é uma das causas mais prevalentes de incapacidade no mundo, e os efeitos adversos promovidos pelos analgésicos podem limitar o sucesso terapêutico. Nesse contexto, surge o laser como terapia complementar que pode potencializar a analgesia, sem aumentar incidência de eventos adversos indesejáveis. O objetivo deste estudo foi realizar uma revisão sistemática sobre a eficácia e a eficiência do laser de alta intensidade (LAI) no tratamento da dor. CONTEÚDO: Foi realizada uma busca sistemática nas plataformas Medline, LILACS, Pubmed e PEDro, de julho de 2020 a agosto de 2022. As palavras chaves dor, dor crônica, laser de alta intensidade e tratamento foram consideradas. A qualidade dos estudos clínicos selecionados foi avaliada utilizando a escala PEDro. As revisões sistemáticas incluídas foram avaliadas quanto à qualidade metodológica através da ferramenta AMSTAR. A principal medida estudada foi a intensidade de dor. Foram encontrados 227 estudos e com base nos critérios de inclusão e exclusão, 32 artigos foram lidos na íntegra, tendo sido excluído um por não avaliar a dor. As desordens musculoesqueléticas corresponderam a 70,96% das doenças avaliadas e a escala analógica visual (EAV) foi a única ferramenta de mensuração da dor utilizada em 100% dos estudos. Aproximadamente 57% dos estudos tinham alta qualidade metodológica (PEDro=7). Em 53,84% dos ensaios o LAI foi utilizado como intervenção única, e em 46,16% foi associado a exercícios. Em 96,15% dos ensaios clínicos e 100% das revisões sistemáticas, o LAI promoveu alívio da dor. CONCLUSÃO: O LAI é uma modalidade eficaz para analgesia ao promover significativo alívio da dor, rápida recuperação e melhora na qualidade de vida dos pacientes de forma segura. A diversidade nos parâmetros de irradiação (dose, duração, intervalo e número de sessões) empregados, indica a necessidade de mais estudos randomizados para estabelecer sua eficiência em longo prazo.

Assessment of pain and quality of life in patients undergoing cardiac surgery: a cohort study

SUMMARY OBJECTIVE: This study aimed to evaluate postoperative pain and quality of life in patients undergoing median sternotomy. METHODS: A cohort study was carried out on a sample of 30 patients who underwent elective cardiac surgery by longitudinal median sternotomy. Patients were interviewed at Intensive Care Unit discharge and hospital discharge, when the Visual Numeric Scale and the Brief Pain Inventory were applied, and 2 weeks after hospital discharge, when the World Health Organization Quality of Life-Bref questionnaire was administered. The normality of the results was analyzed by the Shapiro-Wilk test, and Wilcoxon Rank Sum and McNemar tests were utilized for the analysis of numerical and categorical variables. For correlation between numerical variables, Spearman's linear correlation test was applied. To compare numerical variables, Mann-Whitney U and Kruskal-Wallis tests were applied. Differences between groups were considered significant when the p-value was <0.05. RESULTS: Between Intensive Care Unit and hospital discharge, there was a reduction in median pain intensity assessed by the Visual Numeric Scale from 5.0 to 2.0 (p<0.001), as well as in eight Brief Pain Inventory parameters: worst pain intensity in the last 24 h (p=0.001), analgesic relief (p=0.035), and pain felt right now (p=0.009); and in interference in daily activities (p<0.001), mood (p=0.017), ability to walk (p<0.001), relationship with other people (p=0.005), and sleep (p=0.006). Higher pain intensity at Intensive Care Unit discharge was associated with worse performance in the psychological domain of quality of life at out-of-hospital follow-up. CONCLUSION: Proper management of post-sternotomy pain in the Intensive Care Unit may imply better quality of life at out-of-hospital follow-up.

Impact of deep resection of endometriosis in the pelvis on urodynamic parameters

Purpose: To evaluate the effects of deep resection of endometriosis in the posterior pelvic region on urodynamic parameters. Methods: A prospective observational study conducted with female patients diagnosed with deep pelvic endometriosis before and after endometriosis resection surgery. Clinical history, image exams, the Female Lower Urinary Tract Symptoms questionnaire, urodynamic examination, cystometry, and voiding study were evaluated. Results: Patients aged 30-39 years old, operative duration of 132.5 minutes, and 2.7 days of hospital stay. Uroflowmetry and cystometry showed tendency for an increase after the surgery in the flow duration, time to maximum flow, and first voiding desire and decreased residual volume and maximum cystometric capacity. Opening, maximum urinary flow, and maximum flow pressure decreased at T1, and the closing parameters increased, although statistically non significant. The variables decreased at T1 in the urodynamic, except for detrusor overactivity. Although we observed a reasonable number of low bladder compliance and abnormal bladder sensation, the results were maintained at T1. General scores for filling and incontinence showed a significant decrease after surgery. Conclusions: A significant response in the patient's perception of urinary function was demonstrated after surgery. It is observed that the surgical procedure did not affect the uroflowmetric and cystometric characteristics of the evaluated patients.

Improved quality of life (EHP-30) in patients with endometriosis after surgical treatment

SUMMARY OBJECTIVE: This study aimed to evaluate the quality of life of patients with endometriosis before and after surgical treatment. METHODS: An observational, longitudinal, and prospective study was conducted with 102 women with pelvic pain and endometriosis that was unimproved by clinical treatment and indicated for surgical treatment. The patients' quality of life was assessed using the 30-item Endometriosis Health Profile (EHP-30) questionnaire before and 3 and 6 months after surgery. The statistical tests were analyzed using the Statistical Package for Social Sciences version 17.0, and the Friedman test was used. RESULTS: There was a reduction in EHP-30 scores 3 and 6 months after surgery compared to before surgery, as well as 6 months after surgery compared to 3 months after surgery, in the central questionnaire (PART 1) and in Sections A, B, C, E, and F (p<0.0001). For Section D, there was a reduction in scores 6 months after surgery compared to before surgery (p<0.0001). CONCLUSION: Surgical treatment of endometriosis improves quality of life in several areas assessed by the EHP-30 questionnaire.

Intraoperative, sociodemographic, and postoperative parameters in individuals undergoing bariatric surgery

SUMMARY OBJECTIVE: This study aimed to comparatively analyze sociodemographic data and postoperative parameters of patients undergoing bypass and sleeve surgeries in a private hospital in São Luís, MA. METHODS: The study was descriptive, prospective, observational, and comparative, with a quantitative approach between August 2020 and July 2021. We analyzed 74 participants of both genders, aged between 18 and 70 years, with 31 undergoing Roux-en-Y gastric bypass surgery and 43 undergoing sleeve gastrectomy surgery. In the postoperative period, sociodemographic characteristics, surgery and anesthesia duration, pain levels, adverse effects, weight loss, and complications from the surgical procedure were analyzed. RESULTS: Males predominated in Roux-en-Y gastric bypass and females in sleeve gastrectomy surgery. Clinical characteristics regarding self-declared ethnicity, age and place of birth, education, and marital status were similar between the studied groups. Roux-en-Y gastric bypass had an average surgery time of 112.14±10.06 min and sleeve gastrectomy 91.11±23.69 min, with a significant difference (p<0.001). Regarding anesthesia time, gastric bypass averaged 160.36±13.99 min and sleeve gastrectomy 154.88±29.10 min, with no statistical difference between groups (p=0.335). Nausea, vomiting, and drowsiness were more common in Sleeve gastrectomy, with no significant difference (p=0.562). Roux-en-Y gastric bypass showed a higher rate of weight loss from 1 month after surgery (14.2±4.15) and more variation in body mass index within 3 months after surgery (32.17±4.76). Complications occurred in a small number of patients. CONCLUSION: The two surgical techniques proved effective in delivering the best results for patients, with the group undergoing bypass showing statistically significant weight loss from 1 month after the surgical procedure.

Tranexamic acid effects in postoperative bleeding outcomes in laparoscopic sleeve gastrectomy: a controlled study

Purpose: To demonstrate through a controlled study whether the use of tranexamic acid in bariatric surgeries is effective for bleeding control. Methods: Prospective, comparative, and double-blind study performed with patients from 18 to 65 years old submitted to bariatric surgery. The selected patients received venous tranexamic acid (TXA) during the induction of anesthesia or not (CG). The anesthesia and thromboprophylaxis protocols were similar among the groups. For statistical analysis, the χ2 and analysis of variance tests were performed at a significance level of p < 0.05, using the statistical program SPSS 21.0®. Results: Sixty-one patients were included in the study, 31 in the control group and 30 in the TXA group (GTXA). In the intraoperative period, the bleeding volume was greater in the CG than in the GTXA. In the postoperative period, the tranexamic acid group had a higher value hematocrit, absence of surgical reoperations due to bleeding complications, and shorter hospitalization time than the control group. Conclusions: The use of tranexamic acid was effective in reducing bleeding rates and of hospital stay length, in addition to demonstrating the clinical safety of its use, for not having been associated with any thromboembolic events.

Weight loss and adherence to postoperative follow-up after vertical gastrectomy for obesity treatment

ABSTRACT Purpose To analyze the effectiveness of vertical gastrectomy in the treatment of obese patients, adherence to clinical follow-up and the influence of factors such as gender and age. Methods This is a retrospective, observational and descriptive study, conducted with patients undergoing vertical gastrectomy, operated at Hospital São Domingos, between January 2016 and July 2018. Results Most patients undergoing vertical gastrectomy were female (n = 193, 72.28%) and had a mean age of37.11 ± 8.96 years old. The loss of follow-up was 56.18%. Among adherent patients (n = 117; 43.82%), most patients were female (n = 89; 76.07%) and had a mean age of 37.92 ± 9.85 years old. The mean body mass index (BMI) of the adherents in the preoperative was 37.85 ± 3.72 kg/m2. Both BMI and excess weight (EW) showed a statistically significant difference between pre- and postoperative period. Percentage of excess weight loss (% EWL) was satisfactory for 96.6% of adherent patients. Older patients had a statistically significant lower % EWL compared to the other groups. Conclusions Vertical gastrectomy was effective in the treatment of obese patients, with significant weight loss.

Comparative analysis between patients undergoing Gastric Bypass and Sleeve Gastroplasty in a private hospital in Sao Luis-MA

Abstract Purpose: To compare the satisfaction levels about the surgery and anesthesia management, and to analyze the postoperative outcomes of patients undergoing Gastric Bypass and Sleeve Gastroplasty surgeries in a private hospital in Sao Luís-MA. Methods: The sample consisted of patients undergoing Bypass and Sleeve bariatric surgeries from August 2018 to August 2019, who were in the range of 18 and 70 years old and had not used drugs or presented cardiac arrhythmias, dilated cardiomyopathy, and conduction disorder heart. Data were collected from the evaluation forms and recorded in a form with closed questions. Results: Most patients were female (Bypass - 56% and Sleeve - 67.4%) and aged between 30 and 39 years old (Bypass - 32% and Sleeve - 55.8%). Information (Bypass - 92% and Sleeve - 86.1%) was the highest satisfaction index found. Sleepiness in the immediate postoperative period (Bypass - 92% and Sleeve - 93%) was the main side effect. There were no postoperative complications in patients between the two types of surgery. Conclusions: Patients submitted to Bypass and Sleeve were completely satisfied with the perioperative management. There was no statistically significant difference when comparing adverse effects between the techniques.

Acerto project: impact on assistance of a public emergency hospital / Projeto acerto: impacto na assistência de um hospital público de emergência

ABSTRACT Background: In Brazil, the goal-based approach was named Project ACERTO and has obtained good results when applied in elective surgeries with shorter hospitalization time, earlier return to activities without increased morbidity and mortality. Aim: To analyze the impact of ACERTO on emergency surgery care. Methods: An intervention study was performed at a trauma hospital. Were compared 452 patients undergoing emergency surgery and followed up by the general surgery service from October to December 2018 (pre-ACERTO, n=243) and from March to June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused postoperative venous hydration, duration of use of catheters, probes and drains, postoperative analgesia, prevention of postoperative vomiting, early mobilization and physiotherapy were evaluated. Results: After the ACERTO implantation there was earlier reintroduction of the diet, the earlier optimal caloric intake, earlier venous hydration withdrawal, higher postoperative analgesia prescription, postoperative vomiting prophylaxis and higher physiotherapy and mobilization prescription were achieved early in all (p<0.01); in the multivariate analysis there was no change in the complication rates observed before and after ACERTO (10.7% vs. 7.7% (p=0.268) and there was a decrease in the length of hospitalization after ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusion: The implementation of the ACERTO project decreased the length of hospital stay, improved medical care provided without increasing the rates of complications evaluated.

RESUMO Racional: No Brasil, a abordagem baseada em metas foi nomeada de Projeto ACERTO e tem obtido bons resultados quando aplicada em operações eletivas com diminuição do tempo de internação, retorno mais precoce as atividades sem incremento de morbimortalidade. Objetivo: Analisar o impacto do ACERTO na assistência prestada em operações de emergência. Métodos: Foi realizado um estudo de intervenção em hospital de trauma. Foram comparados 452 pacientes submetidos à operações de emergência e acompanhados pelo serviço de cirurgia geral no período de outubro a dezembro de 2018 (fase pré-ACERTO, n=243) e no período de março a junho de 2019 (fase pós-ACERTO, n=209). Foram avaliados: reintrodução da dieta, volume de hidratação venosa pós-operatória infundido, tempo de uso de catéteres, sondas e drenos, analgesia pós-operatória, prevenção de vômitos pós-operatórios, mobilização precoce e fisioterapia. Resultados: Após a implantação do ACERTO houve reintrodução mais precoce da dieta, foi atingido o aporte calórico ideal mais precocemente, retirada mais precoce da hidratação venosa, maior prescrição de analgesia pós-operatória, de profilaxia de vômitos pós-operatórios e maior prescrição de fisioterapia e mobilização precoce em todos (p<0,01); na análise multivariada não houve alteração nas taxas de complicações observadas pré e pós-ACERTO (10,7% vs. 7,7% (p=0,268) e houve diminuição do tempo de internação pós-ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusão: A implantação do projeto ACERTO diminuiu o tempo de internação hospitalar, melhorou a assistência médica prestada sem incremento das taxas de complicações avaliadas.

Vertical gastrectomy vs. extended vertical gastrectomy: what is the impact on gastroesophageal reflux disease in obese rats? / Gastrectomia vertical vs. gastrectomia vertical ampliada: qual o impacto na doença do refluxo gastroesofágico em ratos obesos?

ABSTRACT Background: Extended vertical gastrectomy is a variation of the vertical gastrectomy technique requiring studies to elucidate safety in relation to gastroesophageal reflux. Aim: To analyze comparatively vertical gastrectomy (VG) and extended vertical gastrectomy (EVG) in rats with obesity induced by cafeteria diet in relation to the presence of reflux esophagitis, weight loss and macroscopic changes related to the procedures. Methods: Thirty Wistar rats were randomized into three groups, and after the obesity induction period by means of a 28-day cafeteria diet, underwent a simulated surgery (CG), VG and VGA. The animals were followed up for 28 days in the post-operative period, and after euthanasia, the reflux esophagitis evaluation was histopathologically performed. Weight and macroscopy were the other variables; weight was measured weekly and the macroscopic evaluation was performed during euthanasia. Results: All animals presented some degree of inflammation and the presence of at least one inflammation criterion; however, there was no statistically significant difference in the analysis among the groups. In relation to weight loss, the animals in CG showed a gradual increase during the whole experiment, evolving to super-obesity at the end of the study, while the ones with VG and EVG had weight regain after the first post-operative period; however, a less marked regain compared to CG, both for VG and EVG. Conclusion: There is no difference in relation to reflux esophagitis VG and EVG, as well as macroscopic alterations, and both techniques have the ability to control the evolution of weight during postoperative period in relation to CG.

RESUMO Racional: A gastrectomia vertical ampliada é uma variação da técnica da gastrectomia vertical, necessitando de estudos a fim de elucidar a segurança em relação ao refluxo gastroesofágico. Objetivo: Analisar comparativamente gastrectomia vertical (GV) e gastrectomia vertical ampliada (GVA) em ratos com obesidade induzida por dieta cafeteria em relação à presença de esofagite de refluxo, perda de peso e alterações macroscópicas relacionadas aos procedimentos. Método: Trinta ratos Wistar foram randomizados em três grupos, e após período de indução de obesidade por meio de dieta cafeteria de 28 dias, foram submetidos a operação simulada (grupo controle GC), gastrectomia vertical (grupo GV) e gastrectomia vertical ampliada (grupo GVA). Os animais foram acompanhados por 28 dias no pós-operatório e, após a eutanásia, foi realizada a pesquisa de esofagite de refluxo através de avaliação histopatológica. Peso e avaliação macroscópica foram as outras variáveis de estudo, sendo o peso aferido semanalmente e a avaliação macroscópica no momento da eutanásia. Resultados: Todos os animais apresentaram algum grau de inflamação e a presença de ao menos um critério de inflamação, porém, não houve diferença estatisticamente significante na análise entre os grupos. Em relação à perda de peso, os animais do GC apresentaram aumento gradativo durante todo experimento evoluindo para super-obesidade ao término do estudo, enquanto os dos grupos GV e GVA tiveram reganho de peso após a primeira semana do pós-operatório, porém, reganho menos acentuado se comparável ao GC, tanto para GV quanto para GVA. Conclusões: Não há diferença em relação à esofagite de refluxo entre GV e GVA, bem como em relação às alterações macroscópicas. Ambas as técnicas têm capacidade de controlar a evolução do peso no pós-operatório em relação ao grupo controle.

Anesthesia for surgical repair of the pentalogy of Cantrell: case report / Anestesia em cirurgia para correção de pentalogia de Cantrell: relato de caso

Abstract Pentalogy of Cantrell is a congenital anomaly associated with defects in the abdominal wall, sternum, diaphragm, and diaphragmatic pericardium formation, in addition to the development of cardiac abnormalities. It is a rare disease with an estimated incidence of one case for every 65,000 births, being more common in males (60% of cases). It has a reserved prognosis with mortality around 63%, and a maximum of 9 months survival after surgery. There are few case reports addressing the pentalogy of Cantrell, which is justified by the rarity of this pathology. In this report our objective was to describe a surgical case of a female patient and make some anesthetic considerations about this rare congenital malformation.

Resumo A pentalogia de Cantrell é uma anomalia congênita associada a defeitos na formação da parede abdominal, do esterno, diafragma e pericárdio diafragmático, além do desenvolvimento de anomalias cardíacas. É uma doença rara, com incidência estimada em um caso para cada 65.000 nascimentos, mais comum no sexo masculino (60% dos casos). Apresenta prognóstico reservado com mortalidade em torno de 63% e sobrevida após procedimento cirúrgico de no máximo nove meses. São escassos os relatos de casos referentes à pentalogia de Cantrell, o que se justifica pela raridade dessa patologia. Com este relato, os autores objetivam descrever um caso cirúrgico, em paciente do sexo feminino, e tecer algumas considerações anestésicas sobre essa malformação congênita rara.

Intubação de via aérea difícil em paciente com síndrome de Treacher Collins / Difficult airway intubation in a patient with Treacher Collins syndrome - case report

A síndrome de Treacher Collins é uma patologia rara, com gene causador mapeado no braço longo do cromossomo cinco (5q31. 3-q33.3). Conhecida como disostose craniofacial, apresenta-se com hipoplasia malar, hipoplasia mandibular e malformações do pavilhão auricular. Tal condição representa previsão de dificuldade para o ato anestésico de intubação, necessitando de avaliação pré-operatória minuciosa e cuidado intensivo no perioperatório. A anestesia geral costuma ser realizada por indução de anestésicos inalatórios, uma vez que crianças submetidas a procedimentos cirúrgicos são não cooperativas, além de haver dificuldade de se obter acesso venoso. Assim, objetiva-se relatar caso de via aérea de intubação difícil em paciente com síndrome de Treacher Collins, correlacionando às manifestações clínicas, ao diagnóstico e ao tratamento cirúrgico, e revisando a literatura sobre o tema. Relatamos um caso cuja singularidade reside no manejo anestésico diferente dos executados em outros centros médicos, ao abordar pacientes com previsão de via aérea difícil. Ao invés de se utilizar máscara laríngea ou intubação com laringoscópio óptico, procedeu-se a: indução inalatória, sedação sem abolir respiração espontânea, visualização das estruturas para introdução do tubo endotraqueal (Cormack 3), acesso venoso, intubação orotraqueal e, posteriormente, indução anestésica e bloqueio neuromuscular. Julgamos importante divulgar tal relato para expor alternativas na indisponibilidade de certos dispositivos, como o fibroscópio. A técnica de intubação sem máscara laríngea ou fibroscópio em pacientes com síndrome craniofacial pode ocorrer sem intercorrências com a estratégia de não abolir a respiração do paciente, porém com leve sedação, devido à não cooperação e à dificuldade de se obter acesso venoso em crianças. (AU)

Treacher Collins syndrome is a rare disease with the culprit gene mapped on the distal long arm of chromosome five (5q31. 3-q33.3). It is known as craniofacial dysostosis, and presents with malar hypoplasia, mandibular hypoplasia, and pinnae malformations. Such condition represents expected difficult airway intubation during anesthesia, requiring detailed preoperative evaluation, and intensive perioperative care. General anesthesia is usually performed through inhaling anesthetics because children undergoing surgical procedures are not cooperative, and their venous access is difficult. Thus, the aim of the study is to report a case of difficult airway intubation in a patient diagnosed with Treacher Collins syndrome, correlating clinical manifestations, diagnosis e surgical treatment, and reviewing the literature on the subject. We report a case that is unique because the anesthetic management is different from what has been done in other medical centers, since it manages patients with expected difficult airway. Instead of using a laryngeal mask airway (LMA) device or a flexible optical intubation (FOI), an inhaling induction was performed, with preserved spontaneous breathing sedation, and visualization of the structures to receive the endotracheal tube (Cormarck 3), venous access, orotracheal intubation and then, anesthetic induction and neuromuscular block. We consider it important to share this report to give alternatives when some devices, such as the fiberscope, are not available. The intubation technique without laryngeal mask airway device or fiberscope in patients with craniofacial syndrome may take place with no complications, when the patient's spontaneous breathing is not aborted, but with light sedation, because of children's noncooperation, and difficulty venous access. (AU)

Effect of preoperative gabapentin on pain intensity and development of chronic pain after carpal tunnel syndrome surgical treatment in women: randomized, double-blind, placebo-controlled study / Efeito da gabapentina pré-operatória na intensidade da dor e desenvolvimento de dor crônica após o tratamento cirúrgico da síndrome do túnel do carpo em mulheres: estudo randomizado duplo-cego controlado com placebo

ABSTRACT CONTEXT AND OBJECTIVES: Effective postoperative analgesia is important for reducing the incidence of chronic pain. This study evaluated the effect of preoperative gabapentin on postoperative analgesia and the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgical treatment. DESIGN AND SETTINGS: Randomized, double-blind controlled trial, Federal University of São Paulo Pain Clinic. METHODS: Forty patients aged 18 years or over were randomized into two groups: Gabapentin Group received 600 mg of gabapentin preoperatively, one hour prior to surgery, and Control Group received placebo. All the patients received intravenous regional anesthesia comprising 1% lidocaine. Midazolam was used for sedation if needed. Paracetamol was administered for postoperative analgesia as needed. Codeine was used additionally if the paracetamol was insufficient. The following were evaluated: postoperative pain intensity (over a six-month period), incidence of postoperative neuropathic pain (over a six-month period), need for intraoperative sedation, and use of postoperative paracetamol and codeine. The presence of neuropathic pain was established using the DN4 (Douleur Neuropathique 4) questionnaire. Complex regional pain syndrome was diagnosed using the Budapest questionnaire. RESULTS: No differences in the need for sedation, control over postoperative pain or incidence of chronic pain syndromes (neuropathic or complex regional pain syndrome) were observed. No differences in postoperative paracetamol and codeine consumption were observed. CONCLUSIONS: Preoperative gabapentin (600 mg) did not improve postoperative pain control, and did not reduce the incidence of chronic pain among patients undergoing carpal tunnel syndrome surgery.

RESUMO CONTEXTO E OBJETIVOS: Analgesia pós-operatória eficaz é importante para reduzir a incidência de dor crônica. Este estudo avaliou o efeito da gabapentina pré-operatória na analgesia pós-operatória e na incidência de dor crônica em pacientes submetidos à cirurgia para tratamento da síndrome do túnel do carpo. DESENHO E LOCAL: Randomizado, duplo cego, Universidade Federal de São Paulo. MÉTODOS: Os 40 pacientes com 18 anos ou mais de idade foram distribuídos aleatoriamente em dois grupos: o Grupo Gabapentina recebeu 600 mg de gabapentina no pré-operatório uma hora antes da cirurgia, e o Grupo Controle recebeu placebo. Todos os pacientes receberam anestesia regional intravenosa com lidocaína a 1%. Midazolam foi utilizado para sedação, se necessário. Paracetamol foi administrado para analgesia pós-operatória, conforme necessário, e codeína, se o paracetamol fosse insuficiente. Foram avaliados: a intensidade da dor pós-operatória (durante seis meses), a incidência de dor neuropática pós-operatória (durante seis meses), a necessidade de sedação intra-operatória e o uso de paracetamol e codeína no pós-operatório. A presença de dor neuropática foi estabelecida utilizando-se o questionário DN4 (dor neuropática 4). Síndrome de dor regional complexa foi diagnosticada através do questionário Budapeste. RESULTADOS: Não foram observadas diferenças na necessidade de sedação, no controle da dor pós-operatória e na incidência de síndromes dolorosas crônicas (neuropáticas ou síndrome de dor regional complexa). Não foram observadas diferenças no consumo de paracetamol e codeína. CONCLUSÕES: Gabapentina pré-operatória (600 mg) não melhorou o controle da dor pós-operatória e não reduziu a incidência de dor crônica em pacientes submetidos à cirurgia para tratamento da síndrome do túnel do carpo.

Methods for the assessment of opioid-induced hyperalgesia in the perioperative period / Métodos para a avaliação da hiperalgesia induzida por opioides no período perioperatório

BACKGROUND AND OBJECTIVES: Opioid-induced hyperalgesia is a topic not yet fully understood in terms of mechanisms, diagnosis, prevention and treatment. Thus, it seems of great importance to evaluate this phenomenon that negatively affects the treatment of pain. The purpose of this study was to describe what tools to use to evaluate perioperative hyperalgesia. CONTENTS: Several methods have been suggested to evaluate opioid-induced hyperalgesia, such as measure of pain intensity, opioid consumption, and evaluation of secondary hyperalgesia with algometer and Von Frey monofilaments. The measurement of some substances, such as cytokines, glutamate, and dynorphin has also been used. CONCLUSION: There are several ways to evaluate opioidinduced hiperalgesia, easily reproducible tests should be chosen and which have also been described in previous studies. .

JUSTIFICATIVA E OBJETIVOS: A hiperalgesia induzida pelo opioide é um tema ainda não totalmente esclarecido do ponto de vista dos mecanismos, do diagnóstico, da prevenção e do tratamento. Assim, parece de grande importância a avaliação desse fenômeno que afeta de maneira negativa o tratamento da dor. O objetivo deste estudo foi descrever quais instrumentos utilizar para avaliar a hiperalgesia perioperatória. CONTEÚDO: Vários métodos têm sido indicados para avaliar hiperalgesia induzida pelo opioide, tais como medida da intensidade da dor, consumo de opioide, e avaliação da hiperalgesia secundária com algômetro e monofilamentos de Von Frey. A dosagem de certas substâncias, como citocinas, glutamato e dinorfina, também tem sido utilizada. CONCLUSÃO: Existem diversas maneiras de avaliar a hiperalgesia induzida pelo opioide; portanto devem ser escolhidos testes de fácil reprodutibilidade e que também foram descritos em estudos anteriores. .

Arterite de Takayasu na gestação: relato de caso e revisão de literatura / Takayasus's arteritis in pregnancy: case report and literature review / Arteritis de Takayasu en el embarazo: relato de caso y revisión de la literatura

JUSTIFICATIVA E OBJETIVOS: A Arterite de Takayasu (AT) é uma doença idiopática, crônica, inflamatória e progressiva que causa estreitamento, oclusão e aneurismas das artérias sistêmicas e pulmonares, afetando principalmente a aorta e seus ramos. Durante a gestação deve-se estar atento à condução dessas pacientes. O objetivo foi relatar um caso de condução anestésica periparto de uma paciente com AT e fazer uma revisão da literatura. RELATO DE CASO: Gestante de 31 anos com troca de arco aórtico e prótese metálica em válvula aórtica por AT há 4 anos. A gestação prosseguiu sem complicações e a paciente foi internada com 34 semanas para adequação da anticoagulação. Realizou-se cesariana eletiva com 39 semanas de gestação com anestesia peridural contínua. Doses fracionadas de anestésico local foram administradas para garantir a instalação lenta do bloqueio. Paciente permaneceu estável hemodinamicamente e foi encaminhada para pós-operatório na UTI. CONCLUSÕES: Muitas complicações podem ocorrer na gestante com AT. Avaliação cuidadosa da paciente, tratamento das complicações da AT e planejamento anestésico cirúrgico são fundamentais. Manutenção da perfusão orgânica é a principal preocupação nessas pacientes e bloqueios neuroaxiais podem ser utilizados sem prejuízo para mãe ou recém-nato. Na paciente com as complicações da AT compensadas, a monitoração não difere da utilizada rotineiramente em cesarianas. Anestesia peridural contínua de instalação lenta mantém a estabilidade hemodinâmica e permite monitorar a perfusão cerebral através do nível de consciência da gestante. Para evitar hipoperfusão orgânica ou complicações hipertensivas no pós-operatório, a paciente deve permanecer monitorada em unidade intensiva ou semi-intensiva por 24 horas.

BACKGROUND AND OBJECTIVES: Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature. CASE REPORT: This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period. CONCLUSIONS: Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anesthetic-surgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

JUSTIFICATIVA Y OBJETIVOS: La Artritis de Takayasu (AT), es una enfermedad idiopática, crónica, inflamatoria y progresiva, que causa el estrechamiento, la oclusión y los aneurismas de las arterias sistémicas y pulmonares, afectando principalmente a la aorta y a sus ramas. Durante el embarazo, debemos estar atentos al seguimiento de esas pacientes. El objetivo fue relatar un caso de seguimiento anestésico periparto de una paciente con AT y hacer una revisión de la literatura. RELATO DE CASO: Embarazada de 31 años con cambio del arco aórtico y prótesis metálica en válvula aórtica por AT hacía 4 años. El embarazo continuó sin complicaciones y la paciente fue ingresada con 34 semanas para la adecuación de la anticoagulación. Se realizó la cesárea electiva con 39 semanas de embarazo con anestesia epidural continua. Se administraron dosis fraccionadas de anestésico local para garantizar la instalación lenta del bloqueo. La paciente permaneció estable hemodinámicamente y fue derivada al postoperatorio en la UCI. CONCLUSIONES: Muchas complicaciones pueden sobrevenir en la embarazada con AT. La evaluación cuidadosa de la paciente, el tratamiento de las complicaciones de la AT y la planificación anestésica quirúrgica son fundamentales. El mantenimiento de la perfusión orgánica es la principal preocupación en esas pacientes, y los bloqueos neuroaxiales pueden ser utilizados sin miedo de perjudicar a la madre o al recién nacido. En la paciente con las complicaciones de la AT compensadas, la monitorización no es diferente de la utilizada como rutina en cesáreas. La anestesia epidural continua de instalación lenta, mantiene la estabilidad hemodinámica y permite monitorizar la perfusión cerebral a través del nivel de conciencia de la embarazada. Para evitar la hipoperfusión orgánica o las complicaciones hipertensivas en el postoperatorio, la paciente debe permanecer monitorizada en una unidad de cuidados intensivos o semi-intensivos durante 24 horas.

Dor crônica pós-operatória: fisiopatologia, fatores de risco e prevenção / Chronic postoperative pain: pathophysiology, risk factors and prevention

JUSTIFICATIVA E OBJETIVOS: A prevalência da dor crônica pós-operatória (DCPO) é grande, acometendo tanto cirurgias de pequeno porte como as de grande porte. Esse tema vem sendo estudado cada vez mais. O objetivo deste estudo foi descrever aspectos importantes sobre essa síndrome.CONTEÚDO: Descrevem-se os mecanismos da DCPO,os fatores de risco para seu desenvolvimento, a prevenção e o tratamento da dor.CONCLUSÃO: A DCPO afeta a qualidade de vida dos pacientes, é de difícil tratamento sendo a medida mais eficaz a sua prevenção. Com o melhor entendimento das bases fisiopatológicas da perpetuação da dor após um procedimento cirúrgico e dos fatores de risco, novas opções para o seu tratamento estão surgindo. Os reais benefícios da utilização de fármacos usados de forma preventiva estão sendo cada vez mais estudados. Na prevenção da dor as equipes cirúrgicas e os pacientes necessitam estar atentas nos riscos de cada procedimento, não somente no perioperatório imediato,mas também em longo prazo.

BACKGROUND AND OBJECTIVES: Chronic postoperative pain (CPOP) prevalence is high, and is manifested both after small and large size surgeries. This subject has been increasingly studied. This study aimed at describing major aspects of this syndrome.CONTENTS: CPOP mechanisms, risk factors for its development, prevention and pain treatments are described.CONCLUSION: CPOP impacts patients' quality of life is diffi cult to treat and the best approach is to prevent it. With a better understanding of pathophysiological bases for perpetuation of pain after a surgical procedure and of risk factors, new treatment options are appearing. The real benefits of preventive drugs are being increasingly studied. To prevent pain, surgical teams and patients have to be aware of the risks of each procedure, not only in the immediate postoperative period but also in the long run.

Hiperalgesia induzida por opioides (HIO) / Opioid-induced hyperalgesia (OIH) / Hiperalgesia inducida por opioides (HIO)

JUSTIFICATIVA E OBJETIVOS: Opioides são medicamentos frequentemente usados para o controle da dor que, contudo, podem causar hiperalgesia. A circunstância pela qual esse fenômeno pode ocorrer não está inteiramente esclarecida. O objetivo desta revisão foi descrever os mecanismos, os fatores implicados e a modulação por medicamentos. CONTEÚDO: Foram descritos os fatores implicados no desenvolvimento da hiperalgesia induzida por opioides (HIO), como duração de uso, dose e tipo de opioide. Os mecanismos incluem o sistema glutamatérgico e receptores N-metil-D-aspartato (NMDA), ativação de ciclo-oxigenase (COX) espinal, aminoácidos excitatórios, dinorfina, citocinas e quimocinas; prostaglandinas e facilitação descendente. A modulação de hiperalgesia pode ser feita com antagonistas de receptores NMDA, agonistas adrenérgicos-alfa2 e inibidores de COX. CONCLUSÕES: O assunto é bastante complexo, envolvendo uma série de mecanismos fisiopatológicos que podem contribuir para a HIO e o desconforto do paciente, trazendo consequências que podem ser danosas.

BACKGROUND AND OBJECTIVES: Opioids are commonly used for pain control; however, they can cause hyperalgesia. The reason why this can happen is not known. The objective of this review was to describe the mechanisms, factors implicated, and drug modulation. CONTENTS: The factors implicated in the development of opioid-induced hyperalgesia (OIH), such as duration of use, dose, and type of opioids are described. Mechanisms involved include the glutamatergic system and N-methyl-D-aspartate receptors (NMDA), spinal cyclooxygenase (COX) activation, excitatory amino acids, dynorphin, cytokines and chemokines; prostaglandins, and descending facilitation. Modulation of hyperalgesia could be done through: NMDA receptor antagonists, alpha2-adrenergic agonists, and COX inhibitors. CONCLUSIONS: This is a very complex subject, which involves a series of pathophysiological mechanisms that could contribute for OIH and patient discomfort, bringing disastrous consequences.

JUSTIFICATIVA Y OBJETIVOS: Los opioides son medicamentos a menudo usados para el control del dolor y que sin embargo pueden causar hiperalgesia. La circunstancia por la cual ese fenómeno puede ocurrir no está totalmente aclarada. El objetivo de esta revisión es describir los mecanismos, los factores que están involucrados y la modulación por medicamentos. CONTENIDO: Fueron descritos los factores involucrados en el desarrollo de la hiperalgia inducida por opioides (HIO), como la duración en el uso, la dosis y el tipo de opioide. Los mecanismos incluyen los sistemas glutamatérgico y los receptores N-metil-D-aspartato (NMDA), activación de ciclo-oxigenasa (COX) espinal, aminoácidos excitatorios, dinorfina, citocinas y quimocinas; prostaglandinas y facilitación descendiente. La modulación de la hiperalgesia se puede lograr con los antagonistas de receptores NMDA, los agonistas adrenérgicosalfa2 y con los inhibidores de (COX). CONCLUSIONES: El tema es bastante complejo, e involucra una serie de mecanismos fisiopatológicos que pueden contribuir para la HIO y la incomodidad del paciente, con consecuencias dañinas para la salud.

Prevalência de infecção por Leishmania chagasi utilizando os métodos de ELISA ( rK39 e CRUDE ) e intradermorreação de Montenegro em área endêmica do Maranhão, Brasil / Prevalence of infection by Leishmania chagasi using ELISA ( rK39 and CRUDE ) and the Montenegro skin test in an endemic leishmaniasis area of Maranhão, Brazil

Realizou-se estudo prospectivo com 1.520 indivíduos menores de 15 anos no Município de São José de Ribamar, Maranhão, Brasil, de junho de 1994 a janeiro de 1995, com o objetivo de avaliar a prevalência e as características (fatores sócio-econômicos, ambientais e hábitos de vida) associadas à infecção por Leishmania chagasi. Realizou-se Intradermorreação de Montenegro (IDRM) e sorologia por Enzyme Linked Immunosorbant Assay (ELISA-rK39 e CRUDE). Na análise estatística foi utilizado o teste chi2 com correção de Yates, sendo considerado significante um valor de p < 0,05. A prevalência de infecção foi de 61,7 por cento pela IDRM, 19,4 por cento pelo ELISA-rK39 e 19,7 por cento pelo ELISA-CRUDE. Foi observada associação entre leishmaniose na família (p = 0,001), tipo de abastecimento de água (p = 0,000) e aplicação de inseticida (p = 0,000) com a infecção por L. chagasi pela IDRM. Nenhuma associação com infecção por L. chagasi foi observada utilizando-se a sorologia ELISA-rK39 ou CRUDE. Medidas de controle mais efetivas são necessárias para reduzir a prevalência da doença e detectar casos assintomáticos dentre o elevado porcentual de infectados nessa localidade.