Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico / Effectiveness of neurolytic sympathetic plexus block in a descriptive case series of patients with oncological pain / Efetividade do bloqueio neurolítico simpático abdominal em uma série descritiva de casos em pacientes com dor oncológica

Introducción. El dolor es el principal síntoma que se presenta en el 40% de los pacientes oncológicos en tratamiento y en entre el 80% y el 85% de pacientes con la enfermedad avanzada. Dentro de las herramientas farmacológicas, los opioides son una opción con los consecuentes efectos secundarios, momento en el cual los procedimientos intervencionistas adquieren su importancia. El objetivo del artículo es mostrar el impacto sobre el control del dolor y la calidad de vida en paciente con dolor oncológico abdominal sometido a bloqueo celíaco o hipogástrica en un periodo de 3 meses, con el fin de generar conocimiento del tema en el área de la salud. Metodología. Se realizó una serie descriptiva de casos en un período de 3 meses. Se incluyeron 34 pacientes adultos con dolor abdominal de origen oncológico, con propuesta de bloqueo neurolítico de plexos celíacos o hipogástrico superior como método de control del dolor y se realizó un análisis de las variables en el programa estadístico IBM SPSS Versión 19. Resultados. Se encontró alivio del dolor en el 79.4% de los pacientes intervenidos al poco tiempo del procedimiento y de 33.3% a los 3 meses. No se encontró significante mejoría en la calidad de vida evaluada con el cuestionario SF-36. Conclusiones. Se encontró en este estudio que pacientes con índice de Karnofsky <50 tuvieron alta tasa de mortalidad posterior al bloqueo. La técnica de fenolización más radiofrecuencia podrían tener mejor respuesta terapéutica. Son necesarios más estudios para evaluar posibles asociaciones. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Introduction. Pain is the main symptom that occurs in 40% of cancer patients undergoing treatment and between 80% and 85% of patients with advanced cancer. Out of the pharmacological tools, opioids are an option with secondary effects, which makes interventional procedures important. The objective of the article is to demonstrate the impact of celiac or hypogastric plexus block in a three-month period on the pain control and quality of life of patients with abdominal oncological pain in order to generate knowledge of this topic in the healthcare sector. Methodology. A descriptive case series was conducted in a three-month period. Thirtyfour adult patients with oncological abdominal pain with proposed celiac or superior hypogastric plexus block as a method of pain control were included and an analysis was conducted of the variables in the statistical program IBM SPSS Version 19. Results. Pain relief was found in 79.4% of the treated patients shortly after the procedure and in 33.3% of the treated patients after 3 months. No significant improvement was evidenced in the quality of life evaluated with the SF-36 questionnaire. Conclussions. The study found that patients with a Karnofsky performance score of < 50 had a high mortality rate after the block. The technique of phenolization and radiofrequency could have a better therapeutic response. More studies are needed to assess possible associations. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Introdução. A dor é o principal sintoma que ocorre em 40% dos pacientes oncológicos em tratamento e entre 80% e 85% dos pacientes com a doença avançada. Dentro das ferramentas farmacológicas, os opióides são uma opção com consequentes efeitos colaterais, momento em que os procedimentos intervencionistas se tornam importantes. Objetivo. O objetivo do artigo é mostrar o impacto no controle da dor e na qualidade de vida em pacientes com dor oncológica abdominal submetido a bloqueio celíaco ou do plexo hipogástrico em um período de 3 meses, a fim de gerar conhecimento sobre o assunto na área da saúde. Métodos. Foi feita uma série descritiva de casos durante um período de 3 meses. Foram incluídos 34 pacientes adultos com dor abdominal de origem oncológica, com proposta de bloqueio neurolítico do plexo celíaco ou hipogástrico superior como método de controle da dor e a análise das variáveis foi realizada no programa SPSS statistic 19 IBM. Resultados. Observou-se alívio da dor em 79.4% dos pacientes operados logo após o procedimento e em 33.3% 3 meses depois. Não houve melhora significativa na qualidade de vida avaliada com o questionário SF-36. Discussão. Encontrou-se neste estudo que pacientes com índice de Karnofsky > 50 apresentaram alta taxa de mortalidade após o bloqueio. A técnica de fenolização e a radiofrequência poderiam ter melhor resposta terapêutica. Mais estudos são necessários para avaliar possíveis associações. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Effect of thoracic paravertebral nerve block on postoperative chronic pain in patients undergoing thoracic surgery / 中华麻醉学杂志

Objective To evaluate the effect of thoracic paravertebral nerve block (TPVB) on postoperative chronic pain in patients undergoing thoracic surgery.Methods One hundred and forty patients of both sexes,aged 25-64 yr,with body mass index of 18-24 kg/m2,of American Society of Anesthesiologists physical status Ⅰ or Ⅱ,scheduled for elective thoracoscopic radical resection of lung cancer,were divided into 2 groups (n=70 each) using a random number table method:control group (group C) and TPVB group (group P).Two-point (T4,6) TPVB was performed on the affected side under ultrasound guidance before anesthesia induction,and 0.5％ ropivacaine 20 ml was injected into each puncture site in group P.Sufentanil 0.1 μg/kg was intravenously injected at 10 min before the end of operation in group C.Analgesic pump was connected at the end of operation in two groups,and patient-controlled intravenous analgesia was performed with sufentanil.The patients were followed up after operation.Sufentanil 0.1 μg/kgwas intravenously injected when visual analogue scale score ≥4.The total consumption of sufentanil and the number of requirements for rescue analgesia were recorded at 48 h after operation in both groups.The patients were followed up to 2 months by telephone after operation,the occurrence of postoperative chronic pain was recorded,and the effect of pain on daily life and grade of treatment measures were evaluated.Results Compared with group C,the total consumption of sufentanil and the number of requirements for rescue analgesia were significantly reduced,and the impact of postoperative chronic pain on daily life and grade of treatment measures for pain were decreased in group P (P＜0.05).There was no significant difference in the incidence of postoperative chronic pain between the two groups (P＞ 0.05).Conclusion Although TPVB cannot reduce the incidence of postoperative chronic pain,it can relieve the degree of postoperative chronic pain in patients undergoing thoracic surgery.

Effects of laryngeal mask ventilation combined with continuous nerve block analgesia on postoperative lung infection in elderly patients undergoing the lower extremity orthopedics surgery / 中华老年医学杂志

Objective To investigate effects of laryngeal mask ventilation combined with continuous nerve block analgesia versus the endotracheal intubation under general anesthesia on postoperative lung infection in elderly patients undergoing orthopedic surgery,so as to provide a theoretical basis for a reasonable anesthesia method.Methods A total of 180 elderly patients undergoing lower extremity orthopedic surgery at our hospital from January 2016 to December 2016 were enrolled and randomly divided into two groups.The control group (n =90) were treated with endotracheal intubation under general anesthesia and intravenous analgesia after the operation,and the observation group (n =90)received the ultrasound-guided continuous nerve block analgesia in spontaneous respiration with laryngeal mask ventilation.The anesthetic dosage,awakening time,visual analogue scale(VAS)scores,and incidence of lung infections at 7 days after surgery were compared between the two groups.Pathogenic strains causing lung infections were isolated and identified.Results The anesthetic dosage was lower in the observation group than in the control group(P ＜ 0.05).The awaking time was shorter in the observation group than in the control group[(22.4±4.4) min vs.(34.1±8.5)min,P ＜0.05].The VAS scores under postoperative exercise were lower in the observation group than in the control group(P ＜0.05).The adverse reaction rate after surgery was lower in the observation group than in control group(3.3％ or 3/90 cases vs.41.1％ or 37/90 cases,P ＜0.05).The incidence of lung infections at 7 days after surgery was lower in the observation group than in the control group(3.3％ or 3/90 cases vs.11.1％ or 10/90 cases,P＜0.05).Ten pathogenic strains were isolated from control group,of which 9 strains were gram-negative bacteria,accounting for 90.0％.Three pathogenic strains were isolated from the observation group,of which 2 strains were gram-negative bacteria,accounting for 66.7％.Conclusions Laryngeal mask ventilation combined with continuous nerve block analgesia can reduce the anesthetic dosage,shorten the awaking time,provide a better analgesic effect and decrease the incidence of lung infections in elderly patients undergoing lower extremity orthopedics.The main pathogenic bacteria are gram-negative bacteria.

Bloqueios do neuroeixo: uma revisão entre duas modalidades anestésicas / Central neuraxial blocks: a review between two anesthetic modalities

Objetivo: Levando em consideração a numerosa indicação do bloqueio raquidiano e da perianestesia na prática médica, o objetivo deste trabalho consiste em realizar uma revisão comparativa entre essas duas modalidades anestésicas. Métodos: Foi realizada busca nas bases de dados PubMed/MEDLINE, LILACS e Google acadêmico, e foram usadas as seguintes palavras-chave: Spinal Anesthesia e Epidural Anesthesia. Após isso, os artigos foram filtrados pelos autores. Resultados: na raquianestesia utiliza-se uma pequena dose de anestésico local para produzir uma profunda analgesia sensorial. Por outro lado, na perianestesia necessita-se de uma grande dose de anestésico local. Conclusão: essas duas anestesias neuroaxiais utilizadas na prática pré e pós-cirúrgica são seguras, porém necessitam de cuidados.

Objective: Considering the numerous indications of spinal block and perianesthesia in medical practice, the objective of this study is to perform a comparative review between these two anesthetic modalities. Methods: A search was performed at PubMed®, LILACS® and Google Academic® using the keywords "spinal anesthesia" and "epidural anesthesia". After this, the papers were filtered by the authors. Results: In spinal anesthesia, a small dose of local anesthetic is used to produce a deep sensory analgesia. On the other hand, perianesthesia requires a large dose of local anesthetic. Conclusion: these two neuroaxial blocks used in pre and post-surgical practice safe, although require care.

Bloqueo supraclavicular ecoguiado por abordaje perivascular medial. Descripción anatómica, técnica de bloqueo y cambios de perfusión regionales / Ultrasound guided supraclavicular perivascular block. Anatomical, technical medial approach description and changes in regional perfusion

Abstract Introduction: Supraclavicular block is usually performed using a lateral to medial approach, although a medial to lateral approach is also feasible. Block onset may be evaluated through the sympathetic effect associated with the sensitive and motor blockade. Objective: To describe the ultrasound-guided supraclavicular block using a medial approach, evaluating the sensitive, motor, and sympathetic block onset. Materials and methods: An ultrasound-guided supraclavicular block was performed in a fresh cadaver with 20 ml volume (2 ml of iodine and 1 ml of methylene blue). A CT scan was performed and sagittal sections were obtained. The clinical phase included 10 patients undergoing a medial approach block; the onset of the block was evaluated based on a motor, sensory and sympathetic assessment (measuring flow changes in the humeral artery, the palmar temperature, and the perfusion index). Results: Adequate distribution of the contrast medium was observed in the cadaver, with complete spread through the brachial plexus, both in terms of the CT-reconstruction as in the anatomical cross sections. A significant change in all the sympathetic block parameters was observed 5 min after the bock: temperature (32.5 ± 1.8 °C to 33.4 ± 1.7 °C; p = 0.047), humeral arterial flow (105 ± 70ml/min to192 ± 97ml/min; p = 0.007), and thumb perfusion index (5 ± 3 to 10 ± 3%; p=0.002). The block was effective and uneventful in all patients. Conclusions: This supraclavicular approach achieves a homogeneous distribution throughout the brachial plexus, with high anesthetic efficacy. Regional changes secondary to the sympathetic block occur early after the block.

Resumen Introducción: El bloqueo supraclavicular habitualmente se realiza mediante abordaje lateral a medial, si bien puede realizarse de medial a lateral y su instauración puede evaluarse por el efecto simpático asociado al bloqueo sensitivo y motor. Objetivo: Describir el bloqueo supraclavicular ecoguiado por abordaje medial evaluando la instauración del bloqueo sensitivo, motor y simpático. Materiales y métodos: Se realizó el bloqueo supraclavicular ecoguiado en cadáver fresco con 20ml de volumen (con 2ml de yodo y 1ml de azul de metileno). Se realizó una tomografía computarizada y posteriormente cortes anatómicos sagitales. En la fase clínica se incluyeron 10 pacientes a quienes se les realizó el bloqueo y posteriormente se evaluó la instauración del bloqueo con valoración sensitiva, motora y simpática (cambios en flujo arterial humeral, temperatura palmar y el índice de perfusión). Resultados: En el cadáver se evidenció una adecuada distribución del medio de contraste bañando la totalidad del plexo braquial, tanto en la reconstrucción tomográfica como en los cortes seccionales anatómicos. Alos 5 min del bloqueo se observó un cambio significativo de todos los parámetros de bloqueo simpático: temperatura (32,5 ± 1,8 a 33,4 ± 1,7 。C; p = 0,047), flujo arterial humeral (105 ± 70 a 192 ± 97ml/min; p = 0,007) e índice de perfusión del pulgar (5 ± 3 a 10 ± 3%; p = 0,002). El bloqueo fue efectivo en todos los pacientes y sin complicaciones. Conclusiones: El abordaje supraclavicular propuesto logra una correcta distribución en el plexo braquial con elevada eficacia anestésica. Los cambios regionales secundarios al bloqueo simpático son precoces tras el bloqueo.

Dose-response relationship of anhydrous alcohol for thoracic sympathetic block in treating primary palmar hyperhidrosis / 中华麻醉学杂志

Objective To determine the dose-response relationship of anhydrous alcohol for thorac-ic sympathetic block in treating primary palmar hyperhidrosis. Methods Two hundred patients with prima-ry palmar hyperhidrosis, aged 18-33 yr, grade of palmar sweating 3 or 4, scheduled for elective surgery under thoracic sympathetic block, were divided into 5 different mixture of anhydrous alcohol and iohexol (iohexol : anhydrous alcohol=1 : 5)groups(n=40 each)using a random number table. Under CT guid-ance, thoracic intervertebral puncture was performed between T3and T4until the needle tip reached the spot around T4and above capitis costae. The mixture of anhydrous alcohol 10 ml(group R1), 15 ml(group R2), 20 ml(group R3), 25 ml(group R4)and 30 ml(group R5)and iohexol was injected into the thoracic sympathetic ganglia on both sides. Effective block was defined as the rise in the palm tempera-ture of both hands more than 3℃ and sweating completely disappeared at 10 min after thoracic sympathetic block was performed with anhydrous alcohol. The median effective dose(ED50), ED95and 95% confi-dence interval(CI)of anhydrous alcohol for thoracic sympathetic block in treating primary palmar hyper-hidrosis were calculated by probit analysis. Results The ED50(95% CI)of anhydrous alcohol for thorac-ic sympathetic block in treating primary palmar hyperhidrosis was 1882(1564-2201)ml, and the ED95 (95% CI)was 2806(2420-3812)ml. Conclusion The ED50and ED95of anhydrous alcohol for tho-racic sympathetic block in treating primary palmar hyperhidrosis are 1882 and 2806 ml, respectively.

Effects of magnesium sulphate on the analgestic efficacy of femoral nerve block with ropivacaine / 中国基层医药

Objective To evaluate the effects of magnesium sulphate on the analgestic efficacy of nerve block analgesia with ropivacaine. Methods Sixty cases who used femoral nerve block analgesia after unilateral total knee arthroplasty under the general anesthesia were selected,and according to digital table they were randomly divided into two groups( n=30 each):magnesium sulfate plus ropivacaine( group M) and ropivacaine( group C) . The solution (20mL) of 0. 2% ropivacaine and 0. 15% magnesium sulphate were administered to group M,and 20mL solution of 0.2% ropivacaine was given to the group C. The pain score was measured by visual analogue scale(VAS). The supplementary usage and cumulative dosage of morphine were recorded and the analgesia relevant complications were observed. Results The results of this study indicated that 4h,8h,12h and 24h after the operation,the VAS scores had no statistically significant difference ( all P > 0. 05 ) at rest, which in group M was significantly decreased compared with group C at 12h(t=2. 800,P=0. 009) and 24h(t=2. 934,P=0. 012) after treated with continuous passive motion ( CPM) postoperatively. The cumulative dosages of morphine when patients undergo CPM of knee joint in group M were (2.78 ±0.32)mg,(2.05 ±0.16)mg,respectively,which were significantly lower than those in the groupC[(4.10±0.85)mg,(2.44±0.25)mg](t=7.960,2.632,all P<0.05).No obvious analgesia relevant complications occurred in both two groups. Conclusion Magnesium sulphate can enhance the efficacy of postopera-tive femoral nerve block analgesia with ropivacaine, reduce the usage of morphine without increasing the analgesia relevant complications.

Application of postoperative analgesia of ultrasound guided transversus abdominis plane block in patients undergoing hysterectomy / 中国基层医药

Objective To observe the application effects of postoperative analgesia of ultrasound guided transverses abdominis plane (TAP) block in patients undergoing hysterectomy.Methods 50 patients with hysterectomy under general anesthesia were selected,and they were randomly divided into two groups according to the digital table,25 cases in each group.The patients of group A were injected with 0.45% ropivacaine mesylate 20mL in ultrasound guided bilateral TAP after the end of surgery before extubation,the patients of group B were injected with the same amount of normal saline in ultrasound guided bilateral TAP block.Postoperative patient-controlled intravenous analgesia with sufentanil was provided to all patients.The VAS score of the two groups after operation,the postoperative dosage of sufentanil in 24h and pressing times of analgesia pump,and the satisfaction of patients with postoperative analgesia,and adverse reactions were observed.Results The VAS scores of 2h of group A (0.96±0.74)points vs.group B (1.88±0.73)points (t=4.45);The VAS scores of 4h of group A (1.52±0.65)points vs.group B (2.24±0.72)points (t=3.69);The VAS scores of 8h of group A (1.88±0.44)points vs.group B (2.68±0.56)points (t=5.64);The VAS scores of 12h of group A (2.24±0.52)points vs.group B (2.96±0.54)points (t=4.80);The VAS scores of 24h of group A (2.44±0.51)points vs.group B (3.24±0.44)points (t=5.99);there were statistically significant differences(all P=0.00).The postoperative dosage of sufentanil in 24h[group A (51.60±1.02)μg vs.group B (55.46±1.37)μg,t=11.30,P=0.00],the pressing times of analgesia pump[group A (7.20±2.04)times vs.group B (14.92±2.74)times,t=11.30,P=0.00],the satisfaction of patients with postoperative analgesia[group A (9.20±0.71)points vs.group B (7.52±0.77)points],t=8.03,P=0.00].There were 2 cases of postoperative nausea and vomiting in group B,and 8 cases in group A,the difference was statistically significant(x2=4.50,P=0.03).Conclusion The application of postoperative analgesia of ultrasound guided TAP block in patients undergoing hysterectomy can reduce postoperative intravenous analgesic drug usage,reduce the incidence of adverse reactions induced by drugs,improve patients' comfort and satisfaction,it is suitable for clinical application.

Effects of magnesium sulphate on the analgestic efficacy of femoral nerve block with ropivacaine / 中国基层医药

Objective To evaluate the effects of magnesium sulphate on the analgestic efficacy of nerve block analgesia with ropivacaine. Methods Sixty cases who used femoral nerve block analgesia after unilateral total knee arthroplasty under the general anesthesia were selected,and according to digital table they were randomly divided into two groups( n=30 each):magnesium sulfate plus ropivacaine( group M) and ropivacaine( group C) . The solution (20mL) of 0. 2% ropivacaine and 0. 15% magnesium sulphate were administered to group M,and 20mL solution of 0.2% ropivacaine was given to the group C. The pain score was measured by visual analogue scale(VAS). The supplementary usage and cumulative dosage of morphine were recorded and the analgesia relevant complications were observed. Results The results of this study indicated that 4h,8h,12h and 24h after the operation,the VAS scores had no statistically significant difference ( all P > 0. 05 ) at rest, which in group M was significantly decreased compared with group C at 12h(t=2. 800,P=0. 009) and 24h(t=2. 934,P=0. 012) after treated with continuous passive motion ( CPM) postoperatively. The cumulative dosages of morphine when patients undergo CPM of knee joint in group M were (2.78 ±0.32)mg,(2.05 ±0.16)mg,respectively,which were significantly lower than those in the groupC[(4.10±0.85)mg,(2.44±0.25)mg](t=7.960,2.632,all P<0.05).No obvious analgesia relevant complications occurred in both two groups. Conclusion Magnesium sulphate can enhance the efficacy of postopera-tive femoral nerve block analgesia with ropivacaine, reduce the usage of morphine without increasing the analgesia relevant complications.

Inyección subdural: informe de dos casos / Subdural injection: report of two cases / Injeção subdural: reporte de dois casos

Se presentan dos casos de inyección subdural accidental durante procedimientos epidurales para control del dolor. El primero fue un hombre con dolor lumbar crónico quien sufrió dicha complicación durante la inyección epidural de esteroides por vía interlaminar; el segundo, una mujer con síndrome de hipotensión endocraneana que requirió la aplicación de un parche hemático epidural para controlar múltiples fístulas de LCR, que debió ser abortada en dos ocasiones debido al patrón subdural que se evidenció luego de la administración del medio de contraste. El bloqueo subdural accidental es una complicación rara de la inyección epidural con fines analgésicos o anestésicos. Es de suma importancia la identificación temprana del patrón de distribución subdural y epidural del medio de contraste con el fin de disminuir el riesgo y aumentar la seguridad de los procedimientos en el espacio epidural.

Two cases are reported of accidental subdural injection during epidural procedures for pain control. The first one was a man with chronic lumbar pain who suffered such complication during an epidural injection of steroids using the interlaminar approach. The second one was a woman with intracranial hypotension syndrome who required the application of an epidural blood patch in order to control multiple CSF fistulae. The procedure had to be aborted twice due to the subdural pattern observed after injection of the contrast medium. Accidental subdural block is a rare complication of epidural injection for analgesic or anesthetic procedures.

Se apresentam dois casos ocorridos durante a execução de procedimentos da prática diária do especialista de dor. O primeiro, um doente com diagnóstico de dor lombar crónico quem apresenta uma injeção subdural acidental durante uma injeção epidural de esteroides por via interlaminar; o segundo uma doentecom síndrome de hipotensão endocraniana quem precisou da colocação de um curativo hemático epidural o qual teve que ser abortado em 2 ocasiões devido ao padrão subdural que se evidenciou logo da administração de meio de contraste. O bloqueio subdural acidental é uma rara complicação da injeção epidural com fins analgésicos ou anestésicos. Por tanto, resulta de suma importância a precoce identificação do padrão de distribuição do meio de contraste subdural e epidural com o fim de diminuir o risco e aumentar a segurança dos procedimentos no espaço epidural.

Informe de caso: Anestesia subdural en la paciente obstétrica / Case report: Subdural anesthesia in the obstetric patient

Introduction: Subdural anesthesia is a relatively frequent complication though seldom recognized. It has a broad spectrum of presentations ranging from an unexpectedly high sensory block with limited motor block, to substantial hemodynamic and respiratory involvement. Case presentation: A 22-year old woman undergoing cesarean section under epidural anesthesia with evidence of long-lasting higher than expected sensory block and respiratory distress. Conclusion: Neuraxial anesthesia comprises a number of versatile and safe techniques, though not exempt from complications including subdural anesthesia. We should be aware of this possibility in our clinical practice, know the risk factors and the diagnostic criteria.

Introducción: La anestesia subdural es una complicación de la anestesia neuroaxial relativamente frecuente pero poco reconocida, tiene un espectro de presentación bastante amplio que va desde un bloqueo sensitivo inesperadamente alto con poco bloqueo motor, hasta compromiso hemodinámico y respiratorio importante. Presentación del caso: Mujer de 22 años que es llevada a cesárea con anestesia epidural, con evidencia de bloqueo sensitivo más alto de lo esperado, de larga duración y dificultad respiratoria. Conclusión: La anestesia neuroaxial es un conjunto de técnicas versátiles y seguras, aunque no exentas de complicaciones como lo es la anestesia subdural. En la práctica clínica debemos estar atentos a esta posibilidad, conocer los factores de riesgo y los criterios diagnósticos.

Comparative Study of the Effects of the Retrocrural Celiac Plexus Block Versus Splanchnic Nerve Block, C-arm Guided, for Upper Gastrointestinal Tract Tumors on Pain Relief and the Quality of Life at a Six-month Follow Up

BACKGROUND: The celiac plexus and splanchnic nerves are targets for neurolytic blocks for pain relief from pain caused by upper gastrointestinal tumors. Therefore, we investigated the analgesic effect of a celiac plexus block versus a splanchnic nerve block and the effects of these blocks on the quality of life six months post-intervention for patients with upper GIT tumors. METHODS: Seventy-nine patients with inoperable upper GIT tumors and with severe uncontrolled visceral pain were randomized into two groups. These were Group I, for whom a celiac plexus block was used with a bilateral needle retrocrural technique, and Group II, for whom a splanchnic nerve block with a bilateral needle technique was used. The visual analogue scale for pain (0 to 100), the quality of life via the QLQ-C30 questionnaire, and survival rates were assessed. RESULTS: Pain scores were comparable in both groups in the first week after the block. Significantly more patients retained good analgesia with tramadol in the splanchnic group from 16 weeks onwards (P = 0.005, 0.001, 0.005, 0.001, 0.01). Social and cognitive scales improved significantly from the second week onwards in the splanchnic group. Survival of both groups was comparable. CONCLUSIONS: The results of this study demonstrate that the efficacy of the splanchnic nerve block technique appears to be clinically comparable to a celiac block. All statistically significant differences are of little clinical value.

The Effect of Stellate Ganglion Block on Intractable Lymphedema after Breast Cancer Surgery

Lymphedema of the upper limb after breast cancer surgery is a disease that carries a life-long risk and is difficult to cure once it occurs despite the various treatments which have been developed. Two patients were referred from general surgery department for intractable lymphedema. They were treated with stellate ganglion blocks (SGBs), and the circumferences of the mid-point of their each upper and lower arms were measured on every visit to the pain clinic. A decrease of the circumference in each patient was observed starting after the second injection. A series of blocks were established to maintain a prolonged effect. Both patients were satisfied with less swelling and pain. This case demonstrates the benefits of an SGB for intractable upper limb lymphedema.

Síndrome compartimental en miembros superiores por picadura de abejas: reporte de caso / Compartment syndrome of the upper limbs after bee sting: Case report

Introducción: El síndrome compartimental en la extremidad superior es considerado una urgencia. Puede generar necrosis y pérdida de la funcionalidad de la mano. El principal tratamiento es con fasciotomías. Sin embargo, existen posibilidades terapéuticas que pueden ayudar o evitar la cirugía, siempre y cuando exista la posibilidad rápida de realizar una fasciotomía si la terapia conservadora fracasa. Objetivo:Evaluar la respuesta clínica y la seguridad al tratamiento con bloqueo del ganglio estrellado y analgesia epidural cervical en una paciente con síndrome compartimental de ambos miembros superiores. Métodos y materiales:Estudio descriptivo longitudinal prospectivo tipo reporte de caso en una paciente con síndrome compartimental de ambos miembros superiores en la que se realizó un bloqueo del ganglio estrellado y analgesia epidural cervical como medida en el tratamiento de su enfermedad. Se realizó un seguimiento durante 7 días. Se evaluaron la recuperación de la sensibilidad y de la movilidad en ambas manos, la intensidad del dolor y la mejoría de la cianosis distal bilateral. Resultados:La paciente evoluciona satisfactoriamente, se evidencia recuperación de la sensibilidad y movilidad en ambas manos, con adecuado control del dolory mejoría de la cianosis distal de manera inmediata y bilateral. Conclusiones: El bloqueo simpático y la analgesia epidural cervical son una alternativa terapéutica en el tratamiento integral del síndrome compartimental siempre y cuando el paciente reciba una monitorización continua de los signos de alarma y tenga la disponibilidad inmediata de un cirujano de mano para realizar fasciotomías en caso de que el tratamiento intervencionista falle.

Introduction:The upper limb compartment syndrome is considered an emergency. It may cause necrosis and loss of functionality of the hand. The principal treatment is fasciotomies. However, there are therapeutic possibilities that may help or avoid surgery, provided there is always the option to do a fasciotomy when conservative treatment fails. Objective: To assess the clinical response and treatment safety with stellate ganglion block and cervical epidural anesthesia in a patient with compartment syndrome of both upper limbs. Methods and materials: Descriptive longitudinal prospective study in a case report format, of a patient with compartment syndrome of both upper extremities that underwent a stellate ganglion block and cervical epidural anesthesia for treating her condition. The patient was followed for 7 days. The recovery of sensitivity and the mobility were assessed on both hands, in addition to pain intensity and bilateral distal cyanosis improvement. Results:The patient evolved satisfactorily with evidence of recovery of sensitivity and mobility in both hands, adequate pain control and immediate and bilateral improved distalcyanosis. Conclusions: Sympathetic block and epidural cervical analgesia are a treatment option for the comprehensive approach of the compartment syndrome, as long as the patient receives constant monitoring of any alarm signs and a surgeon is immediately available to do fasciotomies if the intervention therapy fails.

Clinical observation of interscalene joint axillary brachial plexus block guided by nerve stimulator in elderly patients / 中国医师进修杂志

Objective To compare the anesthetic effect of interscalene joint axillary brachial plexus block guided by nerve stimulator or conventional paresthesia in elderly patients with upper extremity surgery.Methods Sixty cases of ASA grade Ⅱ-Ⅲ elderly patients with upper extremity surgery were divided into two groups by random number table.Nerve stimulator group (30 cases) received interscalene joint axillary brachial plexus block guided by nerve stimulator.Paresthesia group (30 cases) received interscalene joint axillary brachial plexus block guided by conventional paresthesia.Both groups used the same local anesthetic:0.375％ ropivacaine,the dosage was 0.4 ml/kg.Anesthetic dose between interscalene and axillary in two groups in half.The operating time,block onset time,duration of analgesia,anesthetic effect [used by visual analogue scale (VAS) scores] and adverse reaction in two groups were observed and recorded.Results The operating time and block onset time in nerve stimulator group were significantly shorter than those in paresthesia group[(5.2 ± 1.7) min vs.(8.6 ± 2.2) min and (19.4 ± 3.2) min vs.(29.0 ± 3.9) min],VAS scores was lower than that in paresthesia group [(0.7 ± 0.4) scores vs.(2.3 ± 0.8) scores],there were significant differences (P ＜ 0.01).There was no significant difference in duration of analgesia between two groups [(12.4 ± 3.6) h vs.(13.1 ± 3.8) h,P ＞0.05].Nerve stimulator group without adverse reactions.Paresthesia group had 5 cases of adverse reactions,including local hematoma in 2 cases,laryngeal recurrent nerve paralysis in 1 case,horner syndrome in 2 cases.Conclusion Interscalene joint axillary brachial plexus block guided by nerve stimulator in elderly patients is accurate positioning,high success rate,good anaesthesia effect,less adverse reaction,and worth promoting in clinical.

Evaluation of the damage caused by clamping or section of cervical sympathetic nerve in rabbits / Avaliação do dano causado pela clipagem ou secção do nervo simpático cervical em coelhos

PURPOSE: To study the macro and microscopic evaluation of the damage caused by clamping or section of cervical sympathetic nerve in rabbits, quantifying the collagen in the lesions. METHODS: Twenty rabbits were divided into two groups of ten, doing in group 1 (section) section of the right cervical sympathetic nerve, while in group 2 (clipping) clipping of the nerve. All rabbits were induced to death on the seventh day after surgery. The macroscopic variables were: consequences of nerve lesion, clip appearance, presence of infection and adhesions around the nerve. Microscopy used hematoxylin-eosin staining to evaluate the stages and the degree of inflammation and necrosis, and F3BA Picrosirius red staining to quantify collagen. Mann-Whitney test was used for comparisons of collagen types I and III between groups. Fisher exact test analyzed the macroscopic variables, the degree of inflammation and necrosis. RESULTS: There was no discontinuity of nerve injury in the clipping group, as well as the clip was closed in all animals. The presence of severe adhesions was significantly higher in the clipping group (p<0.05). There was no significant difference on other variables macroscopically analyzed. There was no significant difference between groups regarding the type of inflammatory process and its intensity, as well as the presence of necrosis and collagen deposition in the nerves. CONCLUSIONS: In the macroscopic evaluation, the section caused discontinuity, which did not occur in the clamping group; there was no development of local infection; the clipping of the cervical sympathetic nerve was linked to the presence of a greater number of adhesions in comparison to the section group. Microscopically, no difference existed in relation to the type and intensity of inflammation reaction between the groups; occurred predominance of chronic and severe inflammation on the specimens; the necrosis was noticed equally in both groups; there was predominance of type I collagen deposition in relation to type III in both groups.

OBJETIVO: Estudar a lesão provocada pela secção e pela clipagem no nervo simpático cervical de coelhos, avaliando-se a macroscopia, microscopia e quantificando-se o colágeno nas lesões. MÉTODOS: Foram utilizados 20 coelhos, distribuídos em dois grupos de dez, sendo nos animais do grupo 1 (secção) realizada secção do nervo simpático cervical direito, enquanto nos do grupo 2 (clipagem) realizada a clipagem desse nervo. Todos os coelhos foram induzidos à morte no sétimo dia de pós-operatório. As variáveis macroscópicas avaliadas foram: presença de lesão de descontinuidade do nervo, aspecto do clipe, presença de infecção e de aderências ao redor do nervo. A microscopia com hematoxilina-eosina foi feita para avaliar as fases, o grau do processo inflamatório e a presença de necrose; a coloração de Picrosirius red F3BA quantificou o colágeno. Utilizou-se o teste de Mann-Whitney nas comparações dos colágenos tipo I e tipo III entre os grupos. As variáveis macroscópicas, o grau do processo inflamatório e presença de necrose foram analisadas pelo teste de Fisher. RESULTADOS: Não houve lesão de descontinuidade do nervo no grupo clipagem, assim como o clipe encontrou-se fechado em todos os animais desse grupo. A presença de aderências intensas foi significativamente maior no grupo clipagem (p<0,05). Não houve diferença significativa quanto às demais variáveis analisadas macroscopicamente. Não houve diferença significativa entre os grupos quanto ao tipo de processo inflamatório e sua intensidade, assim como quanto à presença de necrose e ao depósito de colágeno nos nervos. CONCLUSÕES: Na avaliação macroscópica, a secção causou lesão de descontinuidade, o que não ocorreu na clipagem; não houve desenvolvimento de infecção local; a clipagem do nervo simpático cervical foi associada à presença de maior quantidade de aderências em relação à secção. Na avaliação microscópica reconheceu-se não haver diferença no tipo e na intensidade do processo inflamatório entre os grupos; ocorreu predomínio de processo inflamatório crônico e acentuado; as necroses ocorreram igualmente em ambos os grupos; houve predomínio de depósito de colágeno tipo I em relação ao tipo III em ambos os grupos.

Effect of nerve block combined with sequential analgesia in peri-operative knee arthroscopy / 中国医师进修杂志

ObjectiveTo observe the effect of nerve block combined with sequential analgesia in peri-operative knee arthroscopy.Methods Two hundred patients undergoing knee arthroscopy,were performed lumbar plexus and sciatic nerve block anesthesia by nerve stimulator with ultrasound guidance.Celecoxib was combined for sequential analgesia.The vital signs,the effect of anesthesia in the surgery,the duration of postoperative analgesia,and patient's satisfaction to analgesia were observed to evaluate the clinical effects.ResultsThe vital signs of the patients in the surgery were stable,the effect of anesthesia was good,180 cases of excellent,16 cases of good,4 cases of poor.The duration of postoperative analgesia was 6-10 (8.2 ± 0.5) h.Combined with sequential analgesia program,there was high patient's satisfaction [ excellent 75％ (150/200),good 10％ (20/200),general 10％ (20/200),poor 5％ ( 10/200 ) ].Conclusion The nerve block combined with sequential analgesia is safe and effective in knee arthroscopy,it achieves high patient's satisfaction,this maybe a routine in knee arthroscopy.

Feasibility of using dexmedetomidine as supplement to stellate ganglion block in treatment of trigeminal post-herpetic neuralgia in elderly patients / 中华麻醉学杂志

ObjectiveTo evaluate the feasibility of using dexmedetomidine (Dex) as supplement to stellate ganglion block (SGB) in the treatment of trigcminal post-herpetic neuralgia in elderly patients.MethodsForty-five ASA Ⅱ patients with trigeminal post-herpetic neuralgia aged 65-85 yr weighing 45-85 kg undergoing stellate ganglion block were randomly divided into 3 groups ( n =15 each): group SGB; group Dex 0.4 and 0.6 μg/kg +SGB (groups DS1 and DS2).SGB was performed on the affected side with 0.5％ ropivacaine 8-10 ml.Dex 0.4 and 0.6 μg/kg in normal saline were infused iv over 15 min before SGB in groups DS1 and DS2 respectively.The onset time and duration of block were recorded.Bradycardia,hypotension and respiratory depression were also recorded.The intensity of pain was assessed with VAS scores (0=no pain,10 =worst pain) before and at 1,2,4,8 weeks after SGB.VAS score ≤3 was defined as satisfactory analgesia.The rate of satisfactory analgesia was calculated.ResultsThere was no significant difference in the incidence of bradycardia,hypotension and respiratory depression among the 3 groups.The duration of block was significantly longer and the rate of satisfactory analgesia at 2,4,8 weeks after SGB was significantly higher in groups DS1 and DS2 than in group SGB.There was no significant difference in the onset time,duration of block and the rate of satisfactory analgesia between groups DS1 and DS2.ConclusionSGB with Dex has better therapeutic effect than SGB in elderly patients with trigeminal post-herpetic neuralgia.

Effects of mediastinal block on coronary atherogenesis and hemodynamics in rabbits with hyperlipoidemia / 中华麻醉学杂志

Objective To investigate the effects of mediastinal block(MB)on coronary atherogenesis and hemodynamics in rabbits with hyperlipoidemia.Methods Forty-eight male New Zealand white rabbits were randomly divided into 4 groups(n=12 each):control group received normal diet 150 g/d for 16 weeks,hypercholesterol group received hypercholesterol diet 150 g/d for 16 weeks,thoracic epidurial block(TEB)group received hypercholesterol diet 150 g/d for 16 weeks and TEB was performed from 13th to 16th week with 2% lidocaine 2 mg/kg twice a day,and MB group received hypercholesterol diet 150 g/d for 16 weeks and MB was performed from 13th to 16th week with 2% lidocaine 2 mg/kg twice a day.MAP was measured before and after 1st block was performed.The serum levels of total cholesterol(TC),triglyceride(TG),high density lipoprotein cholesterol(HDL-C)and low density lipoprotein cholesterol(LDL-C)were measured on 1st day,and on4th,6th,8th and 16th week during the experiment.At the end of 16 th week,all rabbits were killed by air embolism.Heart was removed and kept in 10% formalin for a week.The ventricles were transversely sectioned at the level of papillary muscle and slices from the cross section of the ventricles were obtained for determination of the degree of atherosclerosis by microscopy.Results MAP was decreased significandy after TEB in TEB group,while there was no significant changes in MAP after MB in MB group(P＜0.05).The serum levels of TC,TG and LDL-C were significandy higher in hypercholesterol.TEB and MB groups than in control group(P＜0.05 or 0.01).The ratios of atherogenesis and intimal thickening were significantly lower in TEB and MB groups than in hyperoholesterol group(P＜0.01),there was no significant difference between TEB and MB groups.Conclusion Mediastinal block can inhibit the development of coronary atherogenesis in rabbits with hyperlipoidemia to a great degree similar to that of thoracic epidural block,but has no effect on hemodynamics.

Thoracic sympathetic block reduces respiratory system compliance

CONTEXT AND OBJECTIVE: Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefits. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these beneficial and undesirable effects on intraoperative respiratory mechanics. DESIGN AND SETTING: Randomized, double-blind clinical study at a tertiary public hospital. METHODS: Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5 percent bupivacaine, n = 9) or placebo (15 ml 0.9 percent saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, flows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. StudentÆs t test was performed, including confidence intervals (CI). RESULTS: Bupivacaine rose 5 ± 1 dermatomes upwards and 6 ± 1 downwards. LIP was higher in the bupivacaine group (6.2 ± 2.3 versus 3.6 ± 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 ± 31.7 versus 70.2 ± 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference. CONCLUSION: TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

CONTEXTO E OBJETIVO: Os benefícios pós-operatórios da anestesia peridural torácica (APT) na analgesia e respiração após toracotomias são conhecidos. Contudo, bloqueio simpático torácico pode desencadear hiperreatividade das vias aéreas. Este estudo pesou tais efeitos benéficos e indesejáveis na mecânica respiratória intra-operatória. TIPO DE ESTUDO E LOCAL: Estudo clínico, randomizado, duplo-cego realizado em hospital público terciário. MÉTODOS: Uma tabela de números aleatórios dividiu 19 pacientes submetidos a ressecção pulmonar parcial entre duas soluções administradas na APT: ativa (15 ml 0,5 por cento bupivacaína, n = 9) ou placebo (15 ml 0,9 por cento NaCl, n = 10). Ambas continham epinefrina 1:200,000 e morfina 2 mg. Sob anestesia geral, pressões esofágicas e de vias aéreas foram registradas. Curvas de pressão versus volume, pontos de inflexão inferior (PII), resistências e complacências sob volume corrente de 10 ml.kg-1 foram aferidos para sistema respiratório, parede torácica e pulmões. O teste t de Student foi realizado (p < 0,005), incluindo intervalos de confiança (IC). RESULTADOS: A dispersão cefálica e caudal da bupivacaína foi, respectivamente, de 5 ± 1 e de 6 ± 1 dermátomos. A curva PII foi maior no Grupo Bupivacaína (6,2 ± 2,3 versus 3,6 ± 0,6 cm H2O, p = 0,016, IC = -3,4 a -1,8). Complacências do sistema respiratório e pulmões foram maiores no Grupo Placebo (respectivamente 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0,003, IC = 19,1 a 23,7, e 127,2 ± 31,7 versus 70,2 ± 23,1 ml.cm H2O-1, p < 0,001, IC = 61 a 53). Resistências e complacências da parede torácica não mostraram diferenças. CONCLUSÃO: APT diminui a complacência do sistema respiratório por reduzir seu componente pulmonar. Resistências não são afetadas. Sob APT, pressão positiva expiratória final e manobras de recrutamento são recomendáveis.