Urinary retention after lipoabdominoplasty: case report / Retenção urinária após lipoabdominoplastia: relato de caso

Introduction: Postoperative urinary retention may predispose to permanent bladder damage. Risk factors include type of anesthesia, type of surgery, and use of anticholinergics, analgesics, and opioids. Once the lesion is established, complementary urodynamic tests are essential for etiological diagnosis and treatment. The objective of this study is to report a case of a patient with urinary retention in the postoperative period of lipoabdominoplasty. Case Report: 27-year-old female patient, without comorbidities or use of continuous medication. She underwent lipoabdominoplasty and evolved postoperatively with urinary retention and bladder distention, diagnosed as detrusor contractility and sensitivity deficit in the urodynamic study. She was maintained in outpatient follow-up with the surgical team and Urology, with a progressive reduction in urinary catheter use and complete removal in eight months of follow-up. Discussion: The objective of aesthetic plastic surgery is to improve the physical appearance of the body. It is subject to complications like other surgical procedures, and pain seems to be the most frequent. Urinary retention may be secondary to the use of opioids, and its diagnosis in the postoperative period of lipoabdominoplasty still has some obstacles. Plication of the rectus muscle diastasis, liposuction, and the use of a compressive abdominal belt make it difficult to identify a possible bladder distention. An episode of bladder overdistention can result in significant morbidity. Conclusion: The present report demonstrated the good evolution of a patient who developed urinary retention in the postoperative period of lipoabdominoplasty. The main diagnostic hypothesis was that it was secondary to the use of opioids.

Introdução: A retenção urinária pós-operatória pode predispor a danos permanentes à bexiga. Os fatores de risco incluem tipo de anestesia, tipo de cirurgia e uso anticolinérgicos, analgésicos e opioides. Uma vez que a lesão está estabelecida, os exames complementares urodinâmicos são fundamentais para diagnóstico etiológico e tratamento. O objetivo deste trabalho é relatar caso de paciente com quadro de retenção urinária no pós-operatório de lipoabdominoplastia. Relato de Caso: Paciente de 27 anos, sexo feminino, sem comorbidades ou uso de medicamentos contínuos. Foi submetida a lipoabdominoplastia, e evoluiu no pós-operatório com quadro de retenção urinária e bexigoma, diagnosticada como acontratilidade detrusora e déficit de sensibilidade no estudo urodinâmico. Manteve acompanhamento ambulatorial com a equipe cirúrgica e a Urologia, com redução progressiva do uso do cateter vesical e retirada completa em oito meses de seguimento. Discussão: O objetivo da cirurgia plástica estética é melhorar o aspecto físico do corpo. Como os demais procedimentos cirúrgicos, está sujeita a complicações e a dor parece ser a mais frequente. A retenção urinária pode ser secundária ao uso de opioides e seu diagnóstico no pós-operatório da lipoabdominoplastia ainda possui alguns obstáculos. A plicatura da diástase do músculo reto, a lipoaspiração e o uso de cinta abdominal compressiva dificultam a identificação do possível bexigoma. Um episódio de hiperdistensão da bexiga pode resultar em morbidade significativa. Conclusão: O presente relato demonstrou boa evolução de paciente que desenvolveu retenção urinária no pós-operatório de lipoabdominoplastia. A principal hipótese diagnóstica foi de ser secundária ao uso de opioide.

Effect of opioid-sparing analgesia on incidence of sepsis in severely burned patients: a retrospective cohort study / 中华麻醉学杂志

Objective:To evaluate the effects of opioid-sparing analgesia on the incidence of sepsis in severely burned patients in the retrospective cohort study.Methods:The clinical data from patients with severe burns admitted to three teaching hospitals in Guangdong from 2011 to 2020 were retrospectively extracted and analyzed. The patients were divided into 2 groups based on the analgesic regimen within 30 days after injury: continuous opioids analgesia group (continuous opioid infusion at a relative constant rate for more than 72 h) and opioid-sparing analgesia group (patient-controlled intravenous analgesia/intermittent administration/opioid-free analgesia). Patient′s age, severity of burn, inhalation injury and basal pain score at rest were matched by the propensity score at a 1∶1 ratio. The primary outcome measure was the occurrence of sepsis within 90 days of admission. Secondary outcome measures included 30-day and 90-day all-cause mortality, clinical diagnosis of multiple organ dysfunction syndrome, and prevalence of burn wound infection. The amount of opioid used was also recorded.Results:A total of 328 severely burned patients were finally enrolled, with 145 patients in continuous opioid analgesia group and 183 patients in opioid-sparing analgesia group, and 110 pairs of patients (220 cases) were finally matched by the propensity score.Compared with continuous opioid analgesia group, the total consumption of opioid, daily consumption per analgesia, and consumption per burn area were significantly decreased, and the incidence of sepsis and wound infection was decreased( P<0.05), and no significant change was found in the incidence of multiple organ dysfunction syndrome, 30-day and 90-day all-cause mortality in opioid-sparing analgesia group( P>0.05). Conclusions:Compared with the continuous opioid analgesia regimen, opioid-sparing analgesia can reduce the risk of sepsis in severely burned patients.

Application of multimodal low opioid combined with saphenous nerve block analgesia in elderly patients undergoing knee arthroplasty / 中华老年医学杂志

Objective:To investigate the clinical application of multimodal low-opioid combined with saphenous nerve block analgesia in elderly patients undergoing knee arthroplasty.Methods:This study is a randomized controlled study.A total of 60 elderly patients who underwent elective knee arthroplasty in the Department of Orthopedics, the First Hospital of Shanxi Medical University from January 2021 to December 2021 were selected and divided into 2 groups by numerical randomization: mode low opioid analgesia regimen group(observation group)and traditional analgesia regimen group(control group), 30 cases in each group.Observation group: (1)Preemptive analgesia: Oral celecoxib 200 mg, qd.from 3 days before surgery, the mini-mental state examination(MMSE)score was used to evaluate the cognitive function; (2)Intraoperative analgesia: After the prosthesis was installed, choose to inject analgesics around the knee joint(ropivacaine 200 mg, morphine 5 mg, epinephrine 0.25 mg, dexamethasone 5 mg/100 ml normal saline, also known as "cocktail" solution); (3)Postoperative analgesia: After the operation, continuous saphenous nerve block(0.2% ropivacaine, 2 ml/h)was performed under ultrasound guidance, and the dose of nerve block was adjusted according to the degree of rehabilitation training.Control group: no special treatment before and during the operation, traditional postoperative patient-controlled intravenous analgesia(PCIA)was used after the operation, the formula WAs as follows: sufentanil(2 μg/kg)+ flurbiprofen axetil(200-300 mg)+ Tropisetron(5-10 mg). The numerical rating scale(NRS)scores were observed and recorded 1 day before surgery, 6, 12, 24, and 48 hours after surgery; the time of the first active straight leg raising after surgery, the time of landing; the range of motion(ROM)of the knee joint 3, 7, and 14 days after surgery; the American Hospital for Special Surgery Knee Score(HSS)at 14 days, 1, 3, and 6 months after surgery; serum substance P(SP)and interleukin-6(IL-6)concentrations 1 day before surgery and 48 hours after surgery, and adverse events were recorded.Results:Compared with the control group, the patients in the observation group had lower NRS scores at 6, 12, 24, and 48 hours after the operation( t=27.705, 27.532, 21.739, 25.780, all P<0.05); the first active straight leg raising time and the time of landing earlier after the operation, and the knee joint at 3, 7, and 14 days after the operation, the range of motion(ROM)was better( t=35.496, 43.716, 3.766, 5.216, 6.009, all P<0.05). And the American hospital for special surgery knee score(HSS)was higher at 14 days, 1 month, and 3 months after surgery( t=19.247, 32.337, 22.651, all P<0.05), but there was no significant difference at 6 months after surgery.Simultaneously, the serum SP and IL-6 concentrations in the observation group 48 h after the operation were (431.0±11.3)ng/L and(11.9±2.7)ng/L, respectively.Compared with the control group(442.5±15.6)ng/L, (14.4±2.9)ng/L( t=5.362, 4.144, both P<0.05). Compared with the control group, which were lower than those in the incidence of postoperative nausea and vomiting was lower, the length of hospital stay was shorter in the observation group( χ2=4.630, t=3.311, P=0.031, 0.002), and the other indicators had no statistical differences(all P>0.05). Conclusions:Multimodal low-opioid combined with saphenous nerve block analgesia can significantly reduce perioperative pain in elderly patients undergoing knee arthroplasty, improve early postoperative mobility, and speed up postoperative functional recovery.

Orofacial antinociceptive effects of perillyl alcohol associated with codeine and its possible modes of action

Abstract This study evaluated the orofacial antinociceptive effect of (S)-(-)-perillyl alcohol (PA) associated with codeine (C) and investigated the possible molecular anchorage mechanisms of PA. Mice (n = 5 per group) were treated with PA alone and associated with codeine and assigned to the following groups: 75.0 mg/kg PA; 75.0 mg/kg PA + C 30 mg/kg; PA 37.5 mg/kg + C 15.0 mg/kg; C 30.0 mg/kg; and control. Nociception was induced by formalin, capsaicin, and glutamate, and was quantified based on the duration (in seconds) of face grooming. The possible mechanisms of action were evaluated by molecular docking study. In the formalin test, PA75/C30 presented an effect in the neurogenic (p < 0.0001) and inflammatory (p < 0.005) phases. Mice treated with PA75 (p < 0.0001) and PA75/C30 (p < 0.0005) showed a reduced nociceptive behavior in the capsaicin test. Glutamate-induced nociception also was blocked by PA75 (p < 0.0005) and C30 (p < 0.0005). The molecular anchorage analysis indicated high negative binding energy values for the evaluated receptors, especially glutamate receptors (AMPA -79.57 Kcal/mol, mGLUR6 -71.25, and NMDA -66.33 Kcal/mol). PA associated with codeine showed orofacial antinociceptive activity, with theoretical evidence of interaction with glutamate receptors.

Efficacy of compatibility of different opioids for postoperative patient-controlled intravenous analgesia in patients undergoing gastrointestinal surgery / 中华麻醉学杂志

Objective:To evaluate the efficacy of compatibility of different opioids for postoperative patient-controlled intravenous analgesia (PCIA) in the patients undergoing gastrointestinal surgery.Methods:A total of 6 556 patients undergoing PCIA after gastrointestinal surgery in the first affiliated Hospital of Air Force military Medical University from May 2018 to March 2022 were retrospectively collected and divided into sufentanil plus nalbuphine group (SN group), hydromorphine plus nalbuphine group (HN group) and sufentanil group (S group). In SN, HN and S groups, the PCIA solutions contained sufentanil 100 μg+ nalbuphine 40 mg, hydromorphone 10 mg+ nalbuphine 40 mg, sufentanil 200 μg, respectively, in 100 ml of normal saline, and the PCA pump was set up with a background infusion at a rate of 1 ml/h, bolus dose 0.5 ml, and lockout interval 10 min.The demographic data, the number of patients with insufficient analgesia at rest and during activity (visual analog scale score≥4) at 24 and 48 h after operation, adverse reactions, time to first flatus and first postoperative off-bed time were collected.Results:Compared with S group, the incidence of insufficient analgesia at rest and during activity, dizziness, nausea and vomiting, effective pressing times of PCA and consumption of drugs in the analgesic pump were significantly decreased at 24 and 48 h after operation in HN group and SN group, the incidence of drowsiness was decreased at 24 h after operation, and the time to first flatus and first postoperative off-bed time were shortened in HN group, and the incidence of somnolence was increased at 48 h after operation in SN group ( P<0.05). Compared with SN group, the incidence of insufficient analgesia at rest at 24 and 48 h after operation was significantly increased, the incidence of insufficient analgesia during activity, dizziness, nausea and vomiting, effective pressing times of PCA and consumption of drugs in the analgesic pump were decreased, the incidence of drowsiness was increased at 24 h after operation, the incidence of somnolence was decreased at 48 h after operation, and the time to first flatus and first postoperative off-bed time were shortened in HN group ( P<0.05). Conclusions:Hydromorphine mixed with nalbuphine provides better efficacy than sufentanil mixed with nalbuphine and sufentanil and is helpful in shortening the recovery time of gastrointestinal function when used for postoperative PCIA in the patients undergoing gastrointestinal surgery.

Paracetamol como coadyuvante a opioides fuertes en dolor oncológico moderado a intenso: ¿es realmente efectivo? / Paracetamol as an adjuvant to opioids for cancer pain management

Cancer related pain is one of the most frequent and relevant symptoms in patients with malignant tumors, causing a huge impact in their quality of life. According to the Chilean Public Health System Technical Report of the Cancer Pain Control and Palliative Care Program 2013-2014, 90% of cancer patients admitted to the Program experienced pain, being moderate or intense in 34%. International and local standards recommend the use of strong opioids (morphine, methadone, or fentanyl) associated with adjuvants such as paracetamol as an initial strategy for pain management. This recommendation assumes that the use of combined analgesics could allow the use of lower opioid doses to obtain similar analgesic effect, decreasing the occurrence of opioid side effects. However, this technical report also describes that there is uncertainty about the impact of paracetamol as an adjuvant in patients with cancer pain who are already receiving strong opioids. This review aims to describe the current state of the art regarding the role of paracetamol as a coadjuvant in cancer pain patients.

Comparison among subarachnoid opioid mix for cesarean section - An observational study / Comparación de mezcla de Opioides subaracnoideos para cesárea. Estudio observacional

Abstract Introduction Classically, the local anesthetic (LA) has been combined with one lipophilic and another hydrophilic opioid for neuraxial anesthesia in cesarean section. In Colombia, the practice has been the use of morphine hydrochloride with fentanyl, but the occasional shortage of the former triggered an interest in new options. In response to the shortage of morphine in 2017-2018, a contingency plan was developed at the SES Hospital in Caldas, prefilling syringes at the hospital compounding central, with: bupivacaine, morphine and fentanyl (BMF); bupivacaine, fentanyl and hydromorphone (BFH); and bupivacaine and hydromorphone (BH). Hydromorphone has a rapid onset of action, long-lasting effect and is indicated for spinal administration in the safety data sheet; therefore, the advantages of adding fentanyl to this mix are questionable. Objective To compare the clinical analgesic efficacy at the time of the incision and during the first 12 hours after surgery. Methods An observational, analytical study was conducted, using the mixtures BMF, BFH and BH in patients receiving subarachnoid anesthesia for cesarean section. Pain was assessed at the time of the incision, as well as any adverse effects and the pain visual analogue scale over the following 12 hours. Results Of the 71 patients participating in the study, 40.9 % received BMF; 22.5 %, BFH; and 36.6 %, BH. None of the patients experienced pain at the time of the incision. There was no difference in terms of adverse effects among the three groups. The mean difference in the visual analogue scale (VAS) for postoperative pain at 3, 6 and 12 hours was lower in the groups in which hydromorphone was used. Conclusion BFH and BH combinations are comparable to the original preparation in terms of adverse effects, with the advantage of being more effective in controlling postoperative pain.

Resumen Introducción Para anestesia neuroaxial en cesárea, se ha combinado clásicamente el anestésico local (AL) con un opioide lipofílico y otro hidrofílico. En Colombia se ha usado clorhidrato de morfina con fentanilo, pero el ocasional desabastecimiento del primero despertó el interés por nuevas alternativas. En SES Hospital de Caldas se generó un plan de contingencia frente a la escasez de morfina en 2017-2018, pre llenando jeringas en su central de mezclas con: bupivacaína, morfina y fentanilo (BMF); bupivacaína, fentanilo e hidromorfona (BHF); y bupivacaína e hidromorfona (BH). La hidromorfona tiene inicio rápido de acción, efecto prolongado e indicación en ficha técnica por vía espinal, por lo tanto, las ventajas que pudiera generar la adición del fentanilo a esta mezcla son cuestionables. Objetivo Comparar la eficacia analgésica clínica al momento de la incisión y en las primeras 12 horas postoperatorias. Métodos Se realizó un estudio observacional analítico, empleando las mezclas BMF, BHF y BH en pacientes que recibieron anestesia subaracnoidea para cesárea. Se evaluó el dolor a la incisión, los efectos adversos y la escala visual análoga de dolor en las 12 horas siguientes. Resultados De las 71 pacientes del estudio, 40,9 % recibieron BMF; 22,5 %, BHF; y 36,6 %, BH. En ninguna paciente se observó dolor a la incisión. No hubo diferencia en efectos adversos entre los 3 grupos. La diferencia de medias de la escala visual analógica (EVA) para dolor postoperatorio a las 3, 6 y 12 horas, fue menor en los grupos en los que se usó hidromorfona. Conclusiones Las mezclas BHF y BH son equiparables a la preparación tradicional en cuanto a efectos adversos, con la ventaja de ser más efectivas para el control del dolor postoperatorio.

Prescriptions of analgesics and anti-inflammatory drugs in municipalities from a Brazilian Southeast state

Abstract The objective of this study was to describe dental prescriptions of non-steroidal anti-inflammatory drugs (NSAID), opioids, and analgesics dispensed by the Brazilian National Health System (BNHS, SUS in Portuguese) of a Southeastern state from January to December 2017, and to analyze their association with socioeconomic and oral health care services' characteristics at municipal level. Data were collected from the Brazilian Integrated Pharmaceutical Care Management System. Medicines were grouped according to the Anatomical Therapeutic Chemical Classification System. The total number of Defined Daily Doses (DDD) and DDD per 1,000 inhabitants (inhab.) per year were presented and compared between groups of municipalities. Data analysis used the Classification and Regression Tree model performed with IBM SPSS 25.0. The total number of NSAID, opioids, and analgesics prescriptions was 70,747 and accounted for 354,221.13 DDD. The most frequently prescribed medicine was ibuprofen (n = 24,676; 34.88%). The number of dental practitioners in the BNHS per 1,000 inhab. (p < 0.001), first dental appointment coverage (p = 0.010), oral health teams per 1,000 inhab. (p=0.022), and the proportion of rural population (p = 0.014) were variables positively associated with the number of DDD of NSAID per 1,000 inhab. per year. Bolsa Família program coverage per 1,000 inhab. (p = 0.022) was negatively associated with NSAID prescription. Regarding analgesics, first dental appointment coverage (p=0.002) and Bolsa Família program coverage per 1,000 inhab. (p = 0.012) were positively associated with DDD per 1,000 inhab. per year. In conclusion, dental prescriptions of analgesics and NSAID in the BNHS were associated with socioeconomic and oral health care services' characteristics.

Rodízio de Opioides: uma Análise Descritiva / Opioid Switching: a Descriptive Analysis / Rotación de Opioides: un Análisis Descriptivo

Introdução: O uso de opioides deve ser individualizado e a troca por outro opioide pode ser necessária (rodízio de opioide). Objetivo: Identificar como foi realizado o rodízio de opioide e se o efeito desejado foi atingido em pacientes internados em uma unidade especializada em cuidados paliativos oncológicos. Método: Análise post hoc do estudo de perfil de pacientes internados em um hospital público de cuidados paliativos oncológicos no Rio de Janeiro, entre setembro e novembro de 2016. As internações foram acompanhadas longitudinalmente por revisão de prontuário com coleta diária da escala verbal numérica (EVN). A dor foi considerada controlada quando EVN = 0. Doses, via de administração e rodízio (fármaco e motivo) dos opioides foram observados. O tempo para controle da dor foi calculado quando este foi o motivo. Resultados: Foram observados 104 rodízios de opioides em 90 internações (22,5%), sendo 49% entre opioides fortes e 43% de fraco para forte. Principais motivos foram dor (40%) e dispneia (36%). O tempo para EVN = 0 foi 1,6 dias (+/-1,8; IC95% 1,0-2,1), sendo mais demorado na troca por metadona (média 2,7 dias +/-2,5; IC95% 1,0-4,4). Comparando a dose de morfina oral por equipotência analgésica, houve aumento de 10% na dose do opioide de destino, sendo esse aumento maior quando no rodízio por dispneia (38%). Conclusão: Embora o controle de dor tenha sido superior ao descrito por outros trabalhos, o aumento da dose equipotente do opioide não é corroborado por protocolos. Maior vigilância e outros estudos são recomendados na unidade.

Introduction: The use of opioids must be individualized and changing for another opioid may be necessary (opioid switching). Objective: Identify how the opioid switching was performed and whether the desired effect was achieved in patients admitted at a public palliative oncologic care specialized hospital. Method: Post hoc analysis of the profile study of patients admitted to a public oncologic palliative care hospital in Rio de Janeiro between September and November 2016. Hospitalizations were followed longitudinally by reviewing the charts with daily collection of the numeric rating scale (NRS). Pain was considered controlled when NRS = 0. Doses, route of administration, switch (drugs and motif ) of the opioids were observed. The time for pain control was calculated when this was the reason. Results: 104 opioid switching were observed in 90 hospitalizations (22.5%), 49% of which were strong opioids and 43%, from mild to strong. Main reasons were pain (40%) and dyspnea (36%). The time to NRS = 0 was 1.6 days (+/-1.8; 95% CI 1.0-2.1), taking longer to switch to methadone (mean 2.7 days +/-2.5; 95% CI 1.0-4.4). Comparing the dose of oral morphine by analgesic equipotency, a 10% increase in the target opioid dose occurred, and when rotating due to dyspnea (38%), the increase was greater. Conclusion: Although pain control was higher than described in other studies, the increase in the equipotent dose of opioid is not corroborated by protocols. Extensive surveillance and other studies are recommended in the unit.

Introducción: El uso de opioides debe ser individualizado y puede ser necesario cambiarlo por otro opioide (rotación de opioides). Objetivo: Identificar cómo se realizó la rotación de opioides y si el efecto deseado se logró en pacientes ingresados en una unidad especializada en cuidados oncológicos paliativos. Método: Análisis post hoc del estudio de perfil de pacientes ingresados en un hospital público de cuidados paliativos de oncología en Río de Janeiro, entre septiembre y noviembre de 2016. Las hospitalizaciones fueron seguidas longitudinalmente mediante la revisión de los registros médicos con la recopilación diaria de la Escala Numérica Verbal (ENV). El dolor se consideró controlado cuando ENV = 0. Se observaron dosis, vía de administración, rotación (fármacos y motivo) de los opioides. El tiempo para el control del dolor se calculó cuando esta fue la razón. Resultados: Se observaron 104 ruedas de opioides en 90 hospitalizaciones (22,5%), con 49% entre opioides fuertes y 43% de débiles a fuertes. Las razones principales fueron dolor (40%) y disnea (36%). El tiempo para ENV = 0 fue de 1,6 días (+/-1,8; IC del 95%: 1,0-2,1), y tomó más tiempo cambiar a metadona (promedio 2,7 días +/-2,5; IC 95% 1,0-4,4). Comparando la dosis de morfina oral para la equipotencia analgésica, hubo un aumento del 10% en la dosis de opioides objetivos, este aumento fue mayor al rotar debido a la disnea (38%). Conclusión: Aunque el control del dolor fue superior al descrito por otros estudios, el aumento en la dosis equipotente de opioide no es compatible con los protocolos. Se recomienda mayor vigilancia y otros estudios en la unidad.

Effects of esketamine versus opioid analgesics on postoperative cellular immune function in patients undergoing laparoscopic gynecological surgery / 中华麻醉学杂志

Objective:To compare the effects of esketamine and opioids on postoperative cellular immune function in the patients undergoing laparoscopic gynecological surgery.Methods:Fifty patients, of American Society of Anesthesiologists physical statusⅠor Ⅱ, aged 20-65 yr, with height 150-180 cm, weighing 50-80 kg, who underwent laparoscopic non-oncologic gynecological surgery with general anesthesia in the Second Hospital of Shanxi Medical University from September 2020 to February 2021, were divided into 2 groups using a random number table method: esketamine group (group K) and opioid analgesic group (group O), with 25 patients in each group.Anesthesia was induced as follows: esmketamine 0.25-0.50 mg/kg was intravenously injected in group K, sufentanil 0.2-0.4 μg/kg was intravenously injected in group O, and propofol 2 mg/kg and rocuronium 0.6-0.9 mg/kg were intravenously injected in two groups.Anesthesia was maintained as follows: esketamine was intravenously infused at 0.5 mg·kg -1·h -1 in group K, remifentanil was intravenously infused at 10-20 μg·kg -1·h -1 in group O, and propofol 4-10 mg·kg -1·h -1 was intravenously infused, and rocuronium 0.2-0.3 mg/kg was intermittently injected in two groups.Blood samples from elbow veins were collected before anesthesia induction (T 1) and immediately after extubation (T 2) for determination of T lymphocyte subsets (CD3 + , CD4 + , CD8 + , CD4 + CD25 + CD127 low) and NK cells and B lymphocyte (by flow cytometry) and serum interleukin-6 (IL-6) and IL-10 concentrations (by multiplexed fluorescent microsphere immunoassay). Routine blood tests were performed on preoperative day 1 and postoperative day 3, and neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were calculated. Results:Compared with group O, the percentages of CD3 + and CD4 + cells, ratio of CD4 + /CD8 + and percentage of NK cells were significantly increased, serum IL-6 concentrations were decreased, and serum IL-10 concentrations were increased after extubation, white blood cell, monocyte and neutrophil counts were increased, and lymphocyte count was decreased on postoperative day 3 ( P<0.05), and no significant change was found in neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in group K ( P>0.05). Conclusion:Compared with opioid analgesics, esketamine has less inhibition of postoperative cellular immune function in the patients undergoing laparoscopic gynecological surgery.

Differences in pain measurement between nurses and physicians in a teaching hospital / Diferencias en la medición del dolor entre enfermeros y médicos en un hospital universitario

Abstract Introduction: In clinical practice, the administration of opioid analgesics depends on pain intensity records from nurses because they are responsible for determining the severity of the patient's complaints; however, discrepancies regarding pain measurement are often observed between physicians and nurses, which can lead to an inadequate use of analgesics. Objective: To carry out a comparison of pain intensity measurements made by staff physicians and nurses in a teaching hospital during the first 24 hours of hospital stay of patients with movement-related pain. Methods and methods: Retrospective, cross-sectional study. Data were obtained from the pharmacy database and medical records (opioids prescribed for 1 month, pain intensity, and medication management). The medical records of 634 in patients who were prescribed at least 1 dose of an opioid analgesic were reviewed. Results: The average pain score provided by physicians (5.4/10; SEM=0.17) was significantly higher than the average pain score reported by nurses (3.5/10; SEM=0.15) (p<0.05). The intra-class correlation coefficient was 0.371 (95%CI: 0.138-0.563), indicating poor agreement between measurements. Conclusion: A poor agreement between pain measurements made by physicians and nurses during the first 24 hours of hospital stay was found. Bearing in mind that pain measurement is essential for achieving an appropriate treatment, the jointly provision of pain management education programs to doctors and nurses should be considered, so that they assess pain intensity similarly, thus improving the management of inpatients and their quality of life.

Resumen Introducción. En la práctica clínica, la administración de analgésicos opioides depende de los registros de intensidad de dolor realizados por los enfermeros, ya que estos son los responsables de determinar la intensidad de las quejas de los pacientes. Sin embargo, a menudo se observa que existen discrepancias entre médicos y enfermeros profesionales respecto a la medición del dolor, lo que puede llevar a un uso inadecuado de analgésicos. Objetivo. Comparar las intensidades de dolor de pacientes con dolor asociado al movimiento y registradas por médicos y enfermeros de un hospital universitario durante las primeras 24 horas de hospitalización. Materiales y métodos. Estudio retrospectivo de corte trasversal. La información se obtuvo de las historias clínicas y de la base de datos de la farmacia del hospital (opioides prescritos por 1 mes, intensidades de dolor y uso de medicamentos). Se revisaron las historias clínicas de 634 pacientes a los que se les recetó al menos 1 dosis de opioide durante su estancia hospitalaria. Resultados. El puntaje promedio de dolor registrado en el grupo de médicos fue significativamente mayor (5.4/10, SEM=0.17) que el registrado en el grupo de enfermeros (3.5/10; SEM=0.15) (p<0.05). El coeficiente de correlación intra-clase fue 0.371 (IC95%: 0.138-0.563), lo que indica una pobre concordancia entre las mediciones de médicos y enfermeros. Conclusiones. Se observó una pobre concordancia entre la medición del dolor realizada por los enfermeros y los médicos del hospital. Teniendo en cuenta que la medición del dolor es fundamental para lograr un tratamiento adecuado, debe considerarse ofrecer programas de educación en manejo del dolor a médicos y enfermeros de manera conjunta para que su medición sea uniforme, lo que mejorará el manejo de los pacientes hospitalizados y, por tanto, su calidad de vida.

Recent advances in biology and management of cancer pain / 中国基层医药

Causes of cancer pain are multifactorial and complex.It is an important challenge for the clinicians on how to control cancer pain effectively.Opioids remain the most effective analgesics used in the treatment of cancer pain.But the adverse effects and potential risks associated with chronic use have been paid attention to in clinical work.It is related to molecular discoveries of opioid action that lead to the development of new opioid analgesic on potential new targets in treating cancer pain.Meanwhile, non-pharmacological treatments such as neuromodulation and minimally invasive interventional techniques play an important role in management of cancer pain.It is summarized in this article about the recent advances in biology and management of cancer pain.

Effect of sulfentanyl and tropisetron postoperative analgesia pump on perioperative IL-6, TNF-α and insulin resistance in patients undergoing abdominal general anesthesia / 中国基层医药

Objective@#To investigate the effect of sulfentanyl and tropisetron postoperative analgesia pump on perioperative interleukin 6(IL-6), tumor necrosis factor (TNF-α) and insulin resistance in patients undergoing abdominal general anesthesia.@*Methods@#From March 2016 to March 2017, 120 patients undergoing elective abdominal surgery in our hospital were selected, all patients were treated with general anesthesia.The patients were randomly divided into control group and observation group according to the digital table, with 60 cases in each group.The control group was treated with on-demand delivery analgesia.The observation group was treated with sulfentanyl and tropisetron postoperative analgesia pump for postoperative analgesia.The BCS score, VAS score, Ramsay score at the end of operation and after operation were compared.The TNF-α, ISI, IL-6, insulin levels and blood glucose levels of preoperation and postoperation were compared between the two groups.@*Results@#Compared with the control group, the BCS score and Ramsay score of postoperative 0.5d[(2.78±0.57)points, (2.27±0.39)points], postoperative 1d[(3.04±0.48)points, (2.36±0.50)points], postoperative 1.5d[(3.24±0.51)points, (2.43±0.49)points], postoperative 2d[(3.35±0.43)points, (2.51±0.42)points] in the observation group increased (t=-18.604, -8.65, -8.204, -3.967, t=-9.634, -4.864, -4.610, -2.604, all P<0.05), the VAS scores of postoperative 0.5d[(2.4±1.1)points], postoperative 1 d[(1.8±0.8)points], postoperative 1.5d[(1.7±0.5)points], postoperative 2d[(1.7±0.9)points] in the observation group were lower (t=2.082, 4.834, 7.934, 3.098, all P<0.05). Compared with the control group, the insulin, blood sugar, TNF-α, IL-6 of postoperative 0.5d[(7.26±2.17)mU/L, (5.63±0.58)mmol/L, (148.96±20.31)g/L, (120.54±22.27)pg/mL], postoperative 1d[(7.37±1.74)mU/L, (5.34±0.50)mmol/L, (121.35±21.07)μg/L, (116.35±21.01)pg/mL], postoperative 1.5d[(6.57±2.14)mU/L, (5.11±0.50)mmol/L, (114.36±23.99)μg/L, (113.14±18.05)pg/mL], postoperative 2d[(5.87±1.84)mU/L, (4.87±0.51)mmol/L, (100.02±18.13)μg/L, (91.37±14.88)pg/mL] in the observation group were lower (t=9.374, 11.698, 6.455, 10.161, t=8.557, 13.027, 9.990, 8.541, t=6.730, 7.917, 7.811, 2.326, t=8.003, 7.225, 3.839, -7.618, all P<0.05). Compared with the control group, the ISI of postoperative 0.5d[(24.77±0.26)×1 000], postoperative 1d[(25.03±0.21)×1 000], postoperative 1.5d[(29.65±0.17)×1 000], postoperative 2d[(34.54±0.19)×1 000] in the observation group were increased (t=-281.912, -442.121, -248.226, -431.857, all P<0.05).@*Conclusion@#The analgesic effect of sulfentanyl and tropisetron postoperative analgesia pump is good, it can reduce the postoperative stress response and the levels of IL-6 and TNF-α, and reduce the degree of insulin resistance, and can be widely used in clinical.

Effect of sulfentanyl and tropisetron postoperative analgesia pump on perioperative IL -6, TNF -αand insulin resistance in patients undergoing abdominal general anesthesia / 中国基层医药

Objective To investigate the effect of sulfentanyl and tropisetron postoperative analgesia pump on perioperative interleukin 6(IL-6),tumor necrosis factor (TNF-α) and insulin resistance in patients undergoing abdominal general anesthesia.Methods From March 2016 to March 2017,120 patients undergoing elective abdominal surgery in our hospital were selected ,all patients were treated with general anesthesia.The patients were randomly divided into control group and observation group according to the digital table ,with 60 cases in each group.The control group was treated with on -demand delivery analgesia.The observation group was treated with sulfentanyl and tropisetron postoperative analgesia pump for postoperative analgesia.The BCS score,VAS score,Ramsay score at the end of operation and after operation were compared.The TNF-α,ISI,IL-6,insulin levels and blood glucose levels of preoperation and postoperation were compared between the two groups .Results Compared with the control group ,the BCS score and Ramsay score of postoperative 0.5d[(2.78 ±0.57) points,(2.27 ±0.39) points],postoperative 1d [(3.04 ±0.48)points,(2.36 ±0.50) points],postoperative 1.5d[(3.24 ±0.51) points,(2.43 ±0.49) points], postoperative 2d[(3.35 ±0.43) points,(2.51 ±0.42) points] in the observation group increased ( t＝-18.604,-8.65,-8.204,-3.967,t＝-9.634,-4.864,-4.610,-2.604,all P＜0.05),the VAS scores of postopera-tive 0.5d[(2.4 ±1.1) points],postoperative 1 d[(1.8 ±0.8) points],postoperative 1.5d[(1.7 ±0.5) points], postoperative 2d[(1.7 ±0.9)points] in the observation group were lower (t＝2.082,4.834,7.934,3.098,all P＜0.05).Compared with the control group ,the insulin,blood sugar,TNF-α,IL-6 of postoperative 0.5d[(7.26 ± 2.17)mU／L,( 5.63 ±0.58 ) mmol／L, ( 148.96 ±20.31 ) g／L, ( 120.54 ±22.27 ) pg／mL], postoperative 1d [(7.37 ±1.74)mU／L,(5.34 ±0.50)mmol／L,(121.35 ±21.07) μg／L,(116.35 ±21.01) pg／mL],postoperative 1.5d[(6.57 ±2.14)mU／L,(5.11 ±0.50)mmol／L,(114.36 ±23.99)μg／L,(113.14 ±18.05)pg／mL],postoper-ative 2d[(5.87 ±1.84)mU／L,(4.87 ±0.51) mmol／L,(100.02 ±18.13) μg／L,(91.37 ±14.88) pg／mL] in the observation group were lower ( t ＝9.374,11.698,6.455,10.161,t ＝8.557,13.027,9.990,8.541,t ＝6.730, 7.917,7.811,2.326,t＝8.003,7.225,3.839,-7.618,all P＜0.05).Compared with the control group ,the ISI of postoperative 0.5d[(24.77 ±0.26)×1 000],postoperative 1d[(25.03 ±0.21)×1 000], postoperative 1.5d [(29.65 ±0.17)×1 000],postoperative 2d[(34.54 ±0.19)×1 000] in the observation group were increased (t＝-281.912,-442.121,-248.226,-431.857,all P＜0.05).Conclusion The analgesic effect of sulfentanyl and tropisetron postoperative analgesia pump is good ,it can reduce the postoperative stress response and the levels of IL-6 and TNF-α,and reduce the degree of insulin resistance ,and can be widely used in clinical.

Implantação de um protocolo de manejo de dor e redução do consumo de opioides na unidade de terapia intensiva: análise de série temporal interrompida / Pain management protocol implementation and opioid consumption in critical care: an interrupted time series analysis

RESUMO Objetivo: Avaliar o impacto de um protocolo de manejo da dor e redução do consumo de opioides no consumo geral de opioides e nos desfechos clínicos. Métodos: Estudo em centro único, quasi-experimental, retrospectivo, de coortes antes e depois. Utilizamos uma série temporal interrompida para analisar as alterações no nível e na tendência de utilização de diferentes analgésicos. Foram usadas comparações bivariadas nas coortes antes e depois, regressão logística e regressão quantílica para estimativas ajustadas. Resultados: Incluímos 988 pacientes no período pré-intervenção e 1.838 no período pós-intervenção. O consumo de fentanil teve ligeiro aumento gradual antes da intervenção (β = 16; IC95% 7 - 25; p = 0,002), porém diminuiu substancialmente em nível com a intervenção (β = - 128; IC95% -195 - -62; p = 0,001) e, a partir de então, caiu progressivamente (β = - 24; IC95% -35 - -13; p < 0,001). Houve tendência crescente de utilização de dipirona. A duração da ventilação mecânica foi significantemente menor (diferença mediana: - 1 dia; IC95% -1 - 0; p < 0,001), especialmente para pacientes mecanicamente ventilados por períodos mais longos (diferença no 50º percentil: -0,78; IC95% -1,51 - -0,05; p = 0,036; diferença no 75º percentil: -2,23; IC95% -3,47 - -0,98; p < 0,001). Conclusão: Um protocolo de manejo da dor conseguiu reduzir o consumo de fentanil na unidade de terapia intensiva. Esta estratégia se associou com menor duração da ventilação mecânica.

ABSTRACT Objective: To evaluate the impact of an opioid-sparing pain management protocol on overall opioid consumption and clinical outcomes. Methods: This was a single-center, quasi-experimental, retrospective, before and after cohort study. We used an interrupted time series to analyze changes in the levels and trends of the utilization of different analgesics. We used bivariate comparisons in the before and after cohorts as well as logistic regression and quantile regression for adjusted estimates. Results: We included 988 patients in the preintervention period and 1,838 in the postintervention period. Fentanyl consumption was slightly increasing before the intervention (β = 16; 95%CI 7 - 25; p = 0.002) but substantially decreased in level with the intervention (β = - 128; 95%CI -195 - -62; p = 0.001) and then progressively decreased (β = - 24; 95%CI -35 - -13; p < 0.001). There was an increasing trend in the utilization of dipyrone. The mechanical ventilation duration was significantly lower (median difference: - 1 day; 95%CI -1 - 0; p < 0.001), especially for patients who were mechanically ventilated for a longer time (50th percentile difference: -0.78; 95%CI -1.51 - -0.05; p = 0.036; 75th percentile difference: -2.23; 95%CI -3.47 - -0.98; p < 0.001). Conclusion: A pain management protocol could reduce the intensive care unit consumption of fentanyl. This strategy was associated with a shorter mechanical ventilation duration.

Opioids in the immune system: from experimental studies to clinical practice

SUMMARY INTRODUCTION: Opioids interact with both innate and adaptive immune systems and have direct effects on opioid receptors located on immune cells. Research on this topic has provided evidence of the opioid influence on the immune response associated with surgical stress. The immunological effects of opioids are currently being investigated, particularly whether they influence the outcome of surgery or the underlying disease regarding important aspects like infection or cancer progression. This review addresses background research related to the influence of the opioid receptor on the immune system, the immunosuppressive effect associated with major opioids during the perioperative period, and their clinical relevance. The objective of the study was to review the effects of opioids on the immune system. Methods: A search strategy was conducted in PubMed, Embase, and the Cochrane databases using the terms "immunosuppression," "immune system," "surgical procedures," "analgesics," "opioids" and "perioperative care." Results: The immunosuppressive effect of opioids was identified over 30 years ago. They include signaling and acting directly through immune cells, including B and T lymphocytes, NK cells, monocytes, and macrophages, as well as activating the downstream pathways of the hypothalamic-pituitary-adrenal (HPA) axis leading to the production of immunosuppressive glucocorticoids in the peripheral and sympathetic nervous system.

RESUMO INTRODUÇÃO: Os opioides interagem com ambos os sistemas imunes, inato e adaptativo, através de efeitos diretos sobre os receptores dos opioides localizados nas células imunes. As pesquisas neste assunto têm fornecido evidência da influência dos opioides sobre a resposta imune associada ao estresse cirúrgico. Os efeitos imunológicos dos opioides estão sendo pesquisados na atualidade, principalmente se eles determinam o resultado da cirurgia ou doença consequente devido a fatos importantes como infecção ou progressão do câncer. Essa revisão tem como alvo ver antecedentes em pesquisa relativa à influência dos receptores dos opioides no sistema imunológico, o efeito imunossupressor associado com opioides maiores durante o período peri-operatório e sua importância clínica. O objectivo da pesquisa foi revisar os efeitos dos opioides no sistema imunológico. MÉTODOS: Uma estrategia de procura foi dirigida na mídia PubMed, e no cadastro de Embase e The Cochrane, usando os termos "imunosuppressão", "sistema imunológico", "procedimentos cirúrgicos", "analgésicos", "opioides" e "cuidado peri-operatório". RESULTADOS: O efeito imunosuppressor dos opioides foi identificado há mais de 30 anos. Os efeitos imunosupressores incluem sinalização e ação diretamente através das células imunes, mesmo com os linfócitos B e T, células NK, monócitos e macrófagos, também como ativando as vias de corrente do eixo hipotálamo- hipófise- adrenal (HPA) levando à produção de glucocorticoides imunossupresores no sistema nervoso periférico e simpático.

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study / Bloqueio anestésico do quadrado lombar posterior para analgesia na artroplastia total do quadril primária: estudo comparativo

ABSTRACT Objective To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Methods The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Results For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. Conclusion Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III

RESUMO Objetivo Comparar a analgesia e o uso de opioides em pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e pacientes que não receberam o bloqueio do quadrado lombar. Métodos Revisamos os prontuários de pacientes submetidos à artroplastia total do quadril unilateral entre 1º de janeiro de 2017 e 31 de março de 2018, e 238 pacientes foram incluídos no estudo. O desfecho primário foi o consumo de opioides no pós-operatório nas primeiras 24 horas. Os desfechos secundários foram consumo de opioide no intraoperatório, na sala de recuperação pós-anestésica e nas primeiras 48 horas, escores de Escala Visual Analógica de dor pós-operatória, e tempo de permanência na recuperação pós-anestésica. Os desfechos primário e secundários foram comparados entre os pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e aqueles que não receberam o bloqueio do quadrado lombar. Resultados Para o grupo que recebeu o bloqueio, as doses totais de morfina por via oral em 24 horas foram menores (53,82mg±37,41) em comparação ao grupo sem bloqueio (77,59mg±58,42), com p=0,0011. A utilização de opioides foi consistentemente menor para o grupo que recebeu o bloqueio em cada tempo adicional de avaliação até 48 horas. Os escores da Escala Visual Analógica até 12 horas após a cirurgia para os pacientes que receberam o bloqueio do quadrado lombar posterior e o tempo de permanência na sala de recuperação pós-anestésica foram menores para o grupo que recebeu o bloqueio. Conclusão O bloqueio anestésico do quadrado lombar posterior para artroplastia total do quadril primária está associado à diminuição do uso de opioides nas primeiras 48 horas, diminuição do escore de dor da Escala Visual Analógica em até 12 horas, e menor tempo de permanência na sala de recuperação pós-anestésica. Nível de evidência: III

A national study on the use of opioid analgesics in dentistry

Abstract The aim of this study was to assess the frequency of opioid analgesics prescribed by Brazilian dentists, potential regional differences and their association with socioeconomic and health-related factors. Data for all opioid prescriptions by dentists was obtained from the 2012 database of the National Controlled Substances Management System, regulated by the Brazilian Health Surveillance Agency. The number of defined daily doses (DDD) and DDDs per 1,000 inhabitants per day for each Brazilian state were calculated as the primary outcomes. DDDs were compared by regions and Brazilian states. Spearman's rho correlation coefficient was used to determine the influence of the states' characteristics, such as the Human Development Index; poverty; education; number of dentists per 100,000 inhabitants; visit to the dentist; dental care plan; good or very good oral health; number of pharmaceutical establishments per 100,000/inhabitants; and ability to get all prescribed medications. Data analysis was performed using IBM SPSS Statistics 25.0. A total of 141,161 prescriptions for opioids analgesics by 36,929 dentists were recorded, corresponding to 658,855 doses of opioids dispensed in 2012. The most commonly dispensed opioids were codeine associated with paracetamol (83.2%; n = 117,493). The national DDDs per 1,000 inhabitants per day was 0.0093 (range: 0.0002-0.0216). DDD per 1,000 inhabitants per day was positively associated to visits to dentists (rs = 0.630; P < 0.001) and inversely associated to poverty (rs = -0.624; p = 0.001). There are significant differences in opioid prescriptions in dentistry among the Brazilian states. These differences may be associated with non-clinical factors.

Analysis of the effect of patient-controlled analgesia after cesarean section with nabufine and sufentanil / 中国基层医药

Objective@#To compare the effects of alone and combined administration of nalbuphine and sufentanyl for patient-controlled intravenous analgesia (PCIA) after caesarean section.@*Methods@#From June 2017 to December 2017, 90 women undergoing cesarean section in the Sixth Hospital Affiliated to Shanxi Medical University were selected.They were divided into three groups(with 30 cases in each group) using a random number table: sufentanyl 1.5μg/kg group (group S), nalbuphine 2.0mg/kg group (group N) and nalbuphine 1.0mg/kg+ sufentanyl 1μg/kg group (group NS). In each group tropisetron 6 mg was added, and PCIA solution was then diluted to 10mL in normal saline.Postoperative vital signs, visual analogue scale (VAS) score, the highest Ramsay sedation score, number of self-control analgesia and the occurrence of side effects within 24h after operation were recorded.@*Results@#The highest VAS score within 24h after surgery had statistically significant difference among the three groups [group N (2.66±1.09)points > group S (1.45±0.57)points > group NS (0.90±0.55)points](F=40.11, P<0.05). The Ramsay sedation score among the three groups had no statistically significant difference [group S (2.34±0.61)points, group N (3.13±0.63)points, group NS (2.60±0.72)points] (F=11.00, P>0.05). The number of controlled analgesia among the three groups had no statistically significant difference [group S (0.76±0.69), group N (2.93±0.87), group NS (0.54±0.57)] (F=101.11, P>0.05). The incidence rates of adverse reactions of the three groups were 26.66%(8/30), 16.67%(5/30) and 6.66%(2/30), respecyively, the difference was not statistically significant (P>0.05).@*Conclusion@#Combination of nalbuphine and sufentanyl has more significant effect of PCIA after cesarean section than either of the drugs use alone, which is worthy of clinical promotion.