Efficacy of opioids and non-opioid analgesics in the treatment of post procedure pain of burned patients: a narrative review

Abstract Introduction Burns are a common trauma that cause acute severe pain in up to 80% of patients. The objective of this narrative review is to evaluate the efficacy of opioids, non-steroidal anti-inflammatory drugs, paracetamol, gabapentinoids, ketamine, and lidocaine in the treatment of acute pain in burn victims. Methodology The databases explored were PubMed, Embase, ClinicalTrials, and OpenGrey. The included randomized, controlled clinical trials assessed the analgesic efficacy of these drugs on hospitalized patients, had no age limit, patients were in the acute phase of the burn injury and were compared to placebo or other analgesic drugs. Studies describing deep sedation, chronic opioid use, chronic pain, and patients taken to reconstructive surgeries were excluded. The Jadad scale was used to evaluate quality. Results Six randomized controlled clinical trials (397 patients) that evaluated the analgesic efficacy of fentanyl (n = 2), nalbuphine (n = 1), ketamine (n = 1), gabapentin (n = 1), and lidocaine (n = 1) to treat post-procedural pain were included. Fentanyl, nalbuphine, and ketamine were effective, while lidocaine was associated with a slight increase in reported pain and gabapentin showed no significant differences. Two studies were of high quality, one was of medium high quality, and three were of low quality. No studies on the efficacy of NSAIDs or paracetamol were found. Conclusion Evidence of efficacy is very limited. Fentanyl, nalbuphine, and ketamine seem to be effective for controlling acute pain in burn patients, whereas gabapentin and lidocaine did not show any efficacy.

Methylene Blue for the Treatment of Health Conditions: a Scoping Review

HIGHLIGHTS This scoping review summarizes the findings of clinical trials using methylene blue (MB) for the treatment of various health conditions. This research method allowed mapping main findings, clarifying research topics, and identifying gaps in the literature.

Abstract studies evaluating effective drugs for health conditions are of crucial importance for public health. Methylene blue (MB) is an accessible synthetic drug that presents low toxicity and has been used in several health areas due to its effectiveness. Objective: this scoping review aims to provide a comprehensive overview of relevant research regarding the use of MB for the treatment of health conditions. Methods: a five-stage framework Arksey and O'maley scoping review was conducted. The literature was searched in Cochrane Library database using Mesh term "methylene blue". Data were collected by two independent reviewers and submitted to descriptive synthesis. Results: The search resulted in 429 records, from which 16 were included after exclusion criteria were applied. The therapeutic use of MB was identified for acute conditions (malaria and septic shock), chronic conditions (discogenic back pain, bipolar disorder, refractory neuropathic pain, and post-traumatic stress disorder), and postoperative care (vasoplegic syndrome, and pain after haemorrhoidectomy, lumbar discectomy, and traumatic thoracolumbar fixation). Conclusion: there is much evidence emerging from clinical trials about the therapeutic use of MB for acute, chronic, and postoperative conditions; however, many gaps were identified, which open further avenues for future research.

Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial / Comparação entre morfina subaracnoidea e bloqueio do nervo femoral para analgesia após reconstrução ligamentar de joelho: estudo clínico randomizado

Abstract Background and objectives There are no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia. Method Randomized and controlled clinical trial of patients undergoing reconstruction of the Anterior Cruciate Ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The groups C, M, R0,375 and R0,25 was compared with only the previously described technique, subarachnoid morphine (100░µg), or Femoral Nerve Block (BNF) with 25░mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24░hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated. Results Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24░hours. There was a higher incidence of urinary retention in the M group (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 group (30%) than in the M and C groups (0%), with statistical significance (p░<░0.05). Conclusion There was no difference in the intensity of postoperative pain in patients submitted to ACL reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M group and motor block in the R0,375 group.

Resumo Justificativa e objetivos Não há consenso sobre qual é a técnica ideal para prover analgesia em reconstruções ligamentares de joelho. Objetivou‐se comparar a intensidade da dor pós‐operatória desses pacientes sob diferentes modalidades de analgesia. Método Ensaio clínico randomizado e controlado de pacientes submetidos à reconstrução do ligamento cruzado anterior com tendões flexores entre dezembro de 2013 e 2014. Todos os pacientes foram submetidos a raquianestesia e analgesia de resgate com tramadol. Compararam‐se os grupos C, M, R0,375 e R0,25; aos quais se ofertou apenas a técnica anteriormente descrita, morfina subaracnóidea (100 µg) ou bloqueio de nervo femoral com 25 mL de ropivacaína 0,375% e 0,25%, respectivamente. Avaliou‐se intensidade da dor em 6, 12 e 24 horas, idade, sexo, analgesia de resgate, reações adversas e satisfação. Resultados Entre os 83 pacientes elegíveis, observou‐se predomínio do sexo masculino (85,7%) entre 28 e 31 anos. O Grupo C solicitou mais opioide (27,3%) do que os demais grupos, sem significância quando comparados. Não houve diferenças significativas na intensidade da dor em 6, 12 e 24 horas. Houve maior incidência de retenção urinária no Grupo M (23,8%) do que no R0,375 (0%) e de bloqueio motor prolongado do quadríceps no Grupo R0,375 (30%) do que nos Grupos M e C (0%), com significância estatística (p< 0,05). Conclusão Não houve diferença na intensidade da dor pós‐operatória nos pacientes submetidos à reconstrução de ligamento cruzado anterior com tendões flexores sob as modalidades analgésicas avaliadas, apesar do predomínio de retenção urinária no Grupo M e bloqueio motor no Grupo R0,375.

Oxicodona para analgesia de pacientes com dor aguda no período pós-operatório: revisão sistemática de ensaios clínicos randomizados / Oxycodone for postoperative analgesia in patients with acute pain: systematic review of randomized controlled trials / Oxicodona para la analgesia postoperatoria en pacientes con dolor agudo: revisión sistemática de ensayos controlados aleatorios

Objetivo: avaliar o uso da oxicodona em pacientes com dor aguda no período pós-operatório em comparação aos outros opioides. Método: Trata-se de uma revisão sistemática de ensaios clínicos randomizados (ECR's). Foram consultadas as bases de dados PubMed, EMBASE, Cochrane e LILACS até setembro de 2018. Revisores rastrearam ECR's elegíveis; extraíram os dados e avaliaram o risco de viés. Houve análise de conteúdo descritiva dos achados. Resultados: Em 8 ERC's incluídos a ação da oxicodona comparada morfina foi considerada superior em três estudos e igual em dois estudos. A oxicodona comparada ao fentanil foi considerada melhor em dois estudos. Na comparação com o placebo, a oxicodona também se sobressaiu positivamente. Entretanto não foram encontradas evidências robustas e convergentes que indiquem a superioridade da oxicodona. Conclusão: A oxicodona é um analgésico eficaz na dor pós-operatória aguda, entretanto, mais estudos devem ser realizados bem como a realização de avaliações econômicas.(AU)

Objective: Evaluate the use of oxycodone in patients with acute postoperative pain compared to other opioids. Method: This is a systematic review of randomized controlled trials (RCTs). The PubMed, EMBASE, Cochrane, and LILACS databases were consulted until September 2018. Reviewers screened eligible RCTs; extracted data and assessed the risk of bias. There was descriptive content analysis of the findings. Results: In 8 RCTs included the action of oxycodone compared morphine was considered superior in three studies and equal in two studies. Oxycodone compared to fentanyl was considered better in two studies. Compared to placebo, oxycodone also stood out positively. However, no robust and converging evidence was found to indicate the superiority of oxycodone. Conclusion: Oxycodone is an effective analgesic for acute postoperative pain; however, further studies should be performed as well as economic evaluations.(AU)

Objetivo: Evaluar el uso de oxicodona en pacientes con dolor postoperatorio agudo en comparación con otros opioides. Método: esta es una revisión sistemática de ensayos controlados aleatorios (ECA). Las bases de datos PubMed, EMBASE, Cochrane y LILACS fueron consultadas hasta septiembre de 2018. Los revisores seleccionaron los ECA elegibles; extrajo datos y evaluó el riesgo de sesgo. Hubo un análisis de contenido descriptivo de los hallazgos. Resultados: en 8 ECA incluidos, la acción de la oxicodona en comparación con la morfina se consideró superior en tres estudios e igual en dos estudios. La oxicodona en comparación con el fentanilo se consideró mejor en dos estudios. En comparación con el placebo, la oxicodona también se destacó positivamente. Sin embargo, no se encontró evidencia sólida y convergente que indique la superioridad de la oxicodona. Conclusión: la oxicodona es un analgésico eficaz para el dolor postoperatorio agudo; sin embargo, se deben realizar más estudios, así como evaluaciones económicas.(AU)

Calcitonin as an analgesic agent: review of mechanisms of action and clinical applications / Calcitonina como agente analgésico: revisão dos mecanismos de ação e das aplicações clínicas

Abstract Background and objectives: Calcitonin is a polypeptide hormone regulating the metabolism of calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain-ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin-mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain. Method: Many studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies. Conclusion: This study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.

Resumo Justificativa e objetivos: A calcitonina é um hormônio polipeptídico que regula o metabolismo do cálcio no organismo. Por muitos anos a calcitonina tem sido usada para manter e melhorar a densidade mineral óssea e reduzir a incidência de fraturas. Muitos estudos mostraram que a calcitonina teve efeito analgésico em várias condições físicas de dor. Esse efeito de melhoria da dor é irrelevante diante de seu efeito inibidor osteoclástico e de mecanismos, tais como a alteração do canal de Na+ e da expressão do receptor de serotonina, inclusive a hipótese do mecanismo mediado pela endorfina, que foram usados para explicar esse efeito. Neste estudo, fizemos uma revisão completa sobre o papel da calcitonina como agente analgésico em diferentes cenários e investigamos o fato de que a calcitonina pode ser uma medicação viável para aliviar a dor. Método: Muitos estudos centraram no efeito analgésico da calcitonina em várias condições de dor, inclusive dores agudas relacionadas a fraturas vertebrais, metástases, enxaqueca e distrofia simpática reflexa, bem como dores neuropáticas relacionadas a lesões medulares ou ao diabetes e dor fantasma. Além disso, a calcitonina mostrou ser um aditivo útil à anestesia local para o controle mais efecaz da dor pós-operatória ou neuralgia do trigêmeo. Porém, nos deparamos com alguns dados contraditórios em condições como estenose do canal lombar, síndrome complexa da dor regional, dor fantasma e malignidades. Conclusão: Este estudo mostrou que a calcitonina pode ser um analgésico útil em diferentes condições de dor. A calcitonina pode ser considerada um tratamento elegível para as dores agudas relacionadas a fraturas vertebrais e uma opção viável para o tratamento das dores neuropáticas agudas e crônicas em que outros medicamentos podem falhar.

The effect of dexmedetomidine on the acute pain after cardiothoracic surgeries: a systematic review

Abstract Introduction: Acute post-operative pain remains a troublesome complication of cardiothoracic surgeries. Several randomized controlled trials have examined the efficacy of dexmedetomidine as a single or as an adjuvant agent before, during and after surgery. However, no evidence-based conclusion has been reached regarding the advantages of dexmedetomidine over the other analgesics. Objective: To review the effect of dexmedetomidine on acute post-thoracotomy/sternotomy pain. Methods: Medline, SCOPUS, Web of Science, and Cochrane databases were used to search for randomized controlled trials that investigated the analgesia effect of dexmedetomidine on post-thoracotomy/sternotomy pain in adults' patients. The outcomes were postoperative pain intensity or incidence, postoperative analgesia duration, and the number of postoperative analgesic requirements. Results: From 1789 citations, 12 trials including 804 subjects met the inclusion criteria. Most studies showed that pain score was significantly lower in the dexmedetomidine group up to 24 hours after surgery. Two studies reported the significant lower postoperative analgesia requirements and one study reported the significant lower incidence of acute pain after surgery in dexmedetomidine group. Ten studies found that the total consumption of narcotics was significantly lower in the dexmedetomidine group. The most reported complications of dexmedetomidine were nausea/vomiting, bradycardia and hypotension. Conclusion: Dexmedetomidine can be used as a safe and efficient analgesic agent for reducing the postoperative pain and analgesic requirements up to 24 hours after cardiothoracic surgeries. However, further well-designed trials are needed to find the optimal dosage, route, time, and duration of dexmedetomidine administration.

Postoperative local incision analgesia for acute pain treatment in patients with hepatocellular carcinoma

Summary Objective: The present study aimed to investigate the analgesic effect and safety of using local incision analgesia to treat acute postoperative pain in patients with hepatocellular carcinoma (HCC). Method: A cohort of 60 patients undergoing liver cancer resection was randomly divided into three groups (n=20 per group): local incision analgesia (LIA) group, which received local infiltration with ropivacaine combined with a postoperative analgesia pump; intravenous patient-controlled analgesia (PCA) group, which received fentanyl intravenous analgesia postoperatively; and the control group, which received tramadol hydrochloride injection postoperatively according to the NRS scoring system. The postoperative analgesic effect in each group was compared and tumor recurrence (survival) was analyzed using the Kaplan-Meier method. Results: NRS scores, rate of analgesic usage, ambulation time (h) and intestinal function recovery time (h) were significantly reduced in LIA group compared with the control group at each postoperative time point (6, 12, 24 and 48 hours; p<0.05). Additionally, the NRS scores of LIA patients at 12 hours post-surgery was significantly reduced compared with PCA group (p<0.05), and the occurrence of postoperative adverse events in LIA group was significantly lower than that in PCA group (p<0.05). Survival analysis demonstrated that the mean survival time (tumor recurrence) was significantly increased in LIA group compared with the control group (χ2=4.749; p=0.029). Conclusion: Local incision analgesia improves the analgesic effect, causes fewer adverse reactions and increases postoperative survival time. Our study demonstrated that local incision analgesia is a safe and effective method of postoperative pain management following hepatectomy.

Terapêutica anestésica para o alívio da dor aguda pós-colecistectomia videolaparoscópica: revisão sistemática / Anesthetic therapy for acute pain relief after laparoscopic cholecystectomy: systematic review

RESUMO A terapêutica inadequada da dor pós-operatória em colecistectomia videolaparoscópica pode levar a mobilização tardia, insatisfação do paciente, atraso na alta hospitalar e desenvolvimento de dor crônica. Objetivou-se identificar qual a melhor estratégia terapêutica disponível ao anestesiologista na terapia da dor aguda pós-operatória de pacientes submetidos à colecistectomia videolaparoscópica eletiva. Trata-se de revisão sistemática que incluiu 36 artigos completos indexados nas bases de dados Medline, Scopus, Web of Science e LILACS, com recorte temporal de cinco anos (2012 a 2016), resultantes de estudos controlados e randomizados que foram submetidos à análise qualitativa. Em uma proposta de analgesia multimodal, é importante considerar as contraindicações, os efeitos adversos, a dose e o momento ideal das intervenções. Utiliza-se fármacos não opioides, como anti-inflamatórios não esteroides (AINES)/inibidores da ciclo-oxigenase-2 (COX-2), gabapentina/pregabalina, antagonistas dos receptores N-methyl-D-aspartato (NMDA), entre outras. Os opioides podem ser utilizados em doses baixas associadas ou não a terapia multimodal e/ou ficarem restritos aos casos em que a analgesia multimodal não opioide for insuficiente. Conclui-se que não há consenso sobre qual a melhor estratégia analgésica a ser implementada na dor aguda pós-operatória da colecistectomia videolaparoscópica, o que requer sua aplicabilidade de forma individualizada, com base nas evidências científicas encontradas na literatura. Aponta-se como contribuições para o ensino e a prática profissional o enriquecimento teórico das opções medicamentosas analgésicas disponíveis para a terapêutica da dor pós-operatória de pacientes submetidos à colecistectomia videolaparoscópica eletiva, além de alertar a equipe para considerar os efeitos adversos das intervenções implementadas.

ABSTRACT Inappropriate therapy of postoperative pain in laparoscopic cholecystectomy may lead to late mobilization, patient dissatisfaction, delayed hospital discharge, and chronic pain development. Our objective was to identify the best therapeutic strategy available to the anesthesiologist for the acute postoperative pain of patients submitted to elective laparoscopic cholecystectomy. This is a systematic review that included 36 complete articles indexed in the Medline, Scopus, Web of Science and LILACS databases, with a five-year time cut (2012 to 2016), resulting from controlled and randomized studies that were submitted to qualitative analysis. In a proposal for multimodal analgesia, it is important to consider the contraindications, adverse effects, dose and optimal timing of interventions. Non-opioid drugs, such as non-steroidal anti-inflammatory drugs (NSAIDs)/cyclooxygenase-2 (COX-2) inhibitors, gabapentin/pregabalin, N-methyl-D-aspartate (NMDA) receptor antagonists, and others. Opioids may be used at low doses associated with multimodal therapy or are restricted to cases where non-opioid multimodal analgesia is insufficient. We conclude that there is no consensus as to the best analgesic strategy to be implemented in the acute postoperative pain of laparoscopic cholecystectomy, which requires its applicability in an individualized way, based on the scientific evidence found in the literature. As contribution to medical learning and practice, we point out the theoretical enrichment of the analgesic drug options available for the therapy of postoperative pain in patients submitted to elective laparoscopic cholecystectomy, and alert the team to consider the adverse effects of the interventions implemented.

Manejo de exacerbación en endodoncia / Exacerbation management in endodontics

Introducción: la exacerbación endodóntica es un problema con bajo reporte de incidencia que puede ocurrir después de un tratamiento de endodoncia por la agudización de una condición pulpar asintomática, así como por una afección perirradicular. Lesiones mecánicas y químicas se asocian con frecuencia con su aparición, sin embargo, la lesión causada por microorganismos y sus productos es la causa principal y más común de ella. Puede presentarse posterior a la realización del tratamiento en una cita o entre sesiones. Objetivo: reportar un caso de exacerbación en endodoncia y el manejo de esta. Presentación del caso: paciente femenina de 49 años que acude a consulta por dolor e inflamación luego de haber iniciado tratamiento de endodoncia. Se llevó a cabo el manejo clínico y farmacológico de la exacerbación en un diente con diagnóstico de periodontitis apical asintomática. Luego de 5 días se termina el tratamiento de conducto usando mineral trióxido agregado y gutapercha. Posteriormente el diente es restaurado y se realizan controles clínicos y radiográficos. Conclusiones: es posible prevenir este tipo de complicaciones de causa variable identificando factores de riesgo, así como por medio de la experiencia del clínico e instauración de protocolos de atención adecuados(AU)

Introduction: endodontic exacerbation is a problem with low incidence that can occur after endodontic treatment due to the aggravation of an asymptomatic pulp condition, as well as a periradicular affection. Mechanical and chemical injuries are frequently associated with their onset; however, the injury caused by microorganisms and their products is the main and most common cause for it. It can occur after the treatment is performed at an appointment or between sessions. Objective: to report a case of endodontic exacerbation and its management. Case presentation: a 49-year-old female patient presented with pain and inflammation after beginning the endodontic treatment. The clinical and pharmacological management of the exacerbation was carried out in a tooth with diagnosis of asymptomatic apical periodontitis. After 5 days, the root canal treatment is finished using mineral trioxide aggregate and gutta-percha. The tooth is then restored and clinical and radiographic controls are carried out. Conclusions: it is possible to prevent this type of complications of variable cause by identifying risk factors, as well as through the experience of the clinician and the establishment of proper management protocols(AU)

Relación entre el adecuado manejo del dolor agudo perioperatorio e incidencia de dolor crónico no oncológico / Relationship between the adequate management of perioperative acute pain and Incidence of non-oncologic chronic pain

El adecuado manejo perioperatorio del dolor agudo y la elección de la técnica anestésica influyen en la incidencia de complicaciones a corto, mediano y largo plazo, encontrándose en este grupo el desarrollo de dolor crónico no oncológico (DCNO). debido al aumento de la prevalencia de dolor crónico no oncológico y su relación con un manejo inadecuado o insuficiente del dolor agudo en el periodo perioperatorio, hemos realizado una revisión de su fisiopatología, los factores de riesgo y las técnicas preventivas que permitirían mitigar y/o disminuir su incidencia.

The adequate perioperative management of acute pain and the correct choice of the anesthetic technique influence the incidence of complications in the short, medium and long term, being in this group the development of chronic non-oncological pain (CNOP). due to the increase in the prevalence of non-oncological chronic pain and its relation with an inadequate or insufficient management of acute pain in the perioperative period, we have carried out a review of its pathophysiology, risk factors and preventive techniques that would allow mitigating and/or decrease its incidence.

Comparison of two combinations of opioid and non-opioid analgesics for acute periradicular abscess: a randomized clinical trial

Abstract Acute periradicular abscess is a condition characterized by the formation and propagation of pus in the periapical tissues and generally associated with debilitating pain. Objective: The aim of this study was to compare the overall analgesic effectiveness of two combinations of opioid and non-opioid analgesics for acute periradicular abscess. Material and Methods: This study included 26 patients who sought emergency care in a Brazilian dental school. The patients were randomly divided into two groups: Co/Ac - oral prescription of codeine (30 mg) plus acetaminophen (500 mg), every 4 h, for 3 days or Tr/Ac - oral prescription of tramadol hydrochloride (37.5 mg) plus acetaminophen (500 mg) on the same schedule. Two factors were evaluated: (1) pain scores recorded by the patients in a pain diary 6, 12, 24, 48, and 72 h after treatment, using the Visual Analogue Scale; and (2) the occurrence of adverse effects. Results: In both groups, there was a reduction in pain scores over time. For the Co/Ac group, there was a significant reduction in the scores 12, 24, 48, and 72 hours after treatment (P<0.05). In the Tr/Ac group, the scores significantly decreased over time from time point 6 h (P<0.05). Comparing the pain at each time point, the groups were not significantly different (P>0.05), i.e., both treatments were effective in controlling pain caused by APA; however, the combination of Tr/Ac caused more adverse reactions as two patients had to stop using the medication. Conclusion: This study suggests that, considering both analgesic efficacy and safety, the combination of codeine and acetaminophen is more effective to control moderate to severe pain from acute periradicular abscesses.

Dolor postoperatorio, analgesia y presencia de factores de riesgo para dolor crónico en pacientes hospitalizados de un hospital público de Santiago de Chile / Postoperative pain, analgesia and presence of risk factors for chronic postoperative pain in hospitalized patients of a public hospital of Santiago de Chile

INTRODUCCIÓN: el dolor postoperatorio es un importante problema de salud pública, con una elevada incidencia según publicaciones internacionales. el dolor crónico postoperatorio (DCPO) se desarrolla posterior a una cirugía y persiste por más de dos meses, excluyendo otras causas y problemas preexistentes. se han descrito factores de riesgo demográficos, psicosociales y médicos para el desarrollo de dolor crónico postoperatorio (DCPO), siendo el más importante el dolor postoperatorio agudo elevado. actualmente, en Chile se carece de datos locales sobre dolor postoperatorio agudo y crónico. OBJETIVO: evaluar la intensidad del dolor agudo en pacientes post-operados y las medidas analgésicas utilizadas, esto en el contexto de la identificación de los factores de riesgo para el desarrollo de DCPO en pacientes hospitalizados en el servicio de cirugía de un hospital de alta complejidad. MATERRIALES Y MÉTODOS: se realizó un estudio observacional descriptivo de corte transversal retrospectivo. La muestra incluyó a 100 pacientes post-operados seleccionados en forma aleatoria del área de cirugía del Hospital del Salvador entre los meses de septiembre y octubre de 2017. Se realizó una revisión de protocolos operatorios, evoluciones e indicaciones médicas y se registraron edad, sexo, dolor postoperatorio según la escala numérica del dolor (EN) y factores de riesgo de DCPO (cirugía con riesgo de daño nervioso, revisional, abierta, malla, complicaciones postoperatorias, dolor postoperatorio sobre 5, según EN), además del tiempo operatorio. Se realizó un registro electrónico en planilla de excel (Microsoft® Excel® 2011) pre-codificada y diseñada para este fin, resguardando la identidad de los participantes. Los datos obtenidos se expresaron como promedios (con desviación estándar) y medianas. RESULTADOS: se encontró una incidencia de 44% de dolor postoperatorio, con intensidad promedio de 4,4 ± 1,64 puntos entre los pacientes que presentaron dolor en algún grado. el 93% de los pacientes con dolor presentó dolor moderado a severo. en el 98% del total de pacientes se indicó terapia analgésica; de éstos, el 47,95% solo tuvo indicación de antiinflamatorios no esteroidales (AINEs), 39,79% AINEs y paracetamol, 7,14% solo paracetamol y 5,10% otras combinaciones. el 95% de los pacientes presentó uno o más factores de riesgo para DCPO, y el 11%, cuatro o más. DISCUSIÓN: el conocimiento de la incidencia e intensidad local de dolor postoperatorio es un primer paso para optimizar su manejo. la identificación de la población en riesgo de desarrollar DCPO podría permitir implementar a futuro medidas preventivas, que mejoren la calidad de vida de los pacientes postoperados

INTRODUCTION: postoperative pain is an important public health issue, with a high incidence reported in international literature. chronic postoperative pain (CPOP) is developed posterior to a surgical intervention and persists over two months, excluding other causes and preexisting problems. several risk factors for CPOP have been mentioned, including demographic, psicosocial and medical ones; the most relevant being high acute postoperative pain. nowadays, Chile lacks local data of acute and chronic postoperative pain. OBJECTIVES: assess the intensity of acute postoperative pain and the analgesia used, in the context of the identification of risk factors for CPOP in a surgery department of a high complexity hospital. MATERIALS AND METHODS: an observational descriptive tranversal restrospective study was used. the sample was constituted by 100 postsurgical patients selected randomly from the surgical department of the Hospital del Salvador between september and october 2017. a revision of surgical protocols and medical charts was made; age, sex, postsurgical pain according to numeric pain scale (NPS) and risk factors for CPOP (surgery with risk of nervous damage, second look, open, use of mesh, postsurgical complications, postsurgical pain above 5 according to NPS) were registered, besides surgical time. the record was made on an precoded excel sheet (Microsoft® Excel® 2011), designed for this purpose. the identity of the patients was kept anonymous. the data obtained was expressed as mean (with standard deviation) and median. RESULTS: an incidence of 44% of postsurgical pain was found, with mean intensity of 4.4 ± 1.64points between patients that presented any degree of pain.93% from the patients with pain presented moderate to severe pain. 98% from the total of patients had analgesia, from them 47.95% only had non-steroidal antiinflamatory drugs (NSAIDs), 39.79% NSAIDs and acetaminophen, 7.14% only acetaminophen and 5.10% other combinations. 95% of patients had one or more risk factors for CPOP, and 11% four or more of them. DISCUSSION: the knowledge of the incidence and intensity of postsurgical pain is the first step in order to optimize its manage. the identification of the population at risk to develop CPOP could allow the implementation of preventive measures that may improve the quality of life of postsurgical patients.

Dor em urgência odontológica: uso de anti-inflamatórios, corticoides e analgésicos em casos de pulpite aguda irreversível / Pain in dental emergency: anti inflammatory use, steroids and painkillers in cases of irreversible acute pulpitis

O objetivo deste estudo foi avaliar o uso do cetorolaco de trometamina 10mg sublingual 30 minutos antes do procedimento de biopulpectomia em pacientes com pulpite irreversível com relação à dor antes do procedimento e nas 48 horas subsequentes, a quantidade de medicação consumida no pós-operatório e tempo esperado para sua utilização. Também foi avaliada a influência da anestesia intrapulpar, o uso da automedicação analgésica antes da procura pelo atendimento e diferença entre gêneros sobre os níveis de dor pré e pós-operatória. Propôs-se avaliar também a necessidade da presença do antibiótico na medicação intracanal, comparando o Otosporin® com hidrocortisona. Participaram da pesquisa 608 pacientes que procuraram o Setor de Urgência Odontológica da Faculdade de Odontologia de Bauru ou o Setor Odontológico do Pronto Socorro Central da Prefeitura Municipal de Bauru, sendo que 34 completaram de forma adequada o protocolo previsto. Foram divididos em 4 grupos que receberam cetorolaco ou placebo como medicação pré-operatória e Otosporin® ou hidrocortisona como medicação intracanal. Foram anotados os valores de intensidade de dor, em uma escala visual analógica, antes da medicação pré-operatória, antes do atendimento, após o atendimento, 1, 2, 4, 12, 24, 48 horas após e quando houve necessidade de medicação pós-operatória para alívio da dor. Também foi anotado se o paciente havia se automedicado e qual a droga utilizada, se houve necessidade de anestesia intrapulpar, a quantidade de medicação consumida pelo paciente no pós-operatório e o tempo esperado para seu consumo. Dos resultados observou-se que os pacientes que receberam cetorolaco como medicação pré-operatória tiveram uma redução significativa da dor em 30 minutos, quando comparado ao placebo. Foi observado que o tempo necessário para a ingestão de medicamentos pós-operatórios não demonstrou diferença significativa entre os grupos, assim como na quantidade de medicação ingerida. O tempo decorrido entre a primeira e a última dose de medicação pós-operatória também não demonstrou diferença estatística. Com relação a anestesia intrapulpar, 78% dos pacientes necessitaram desta técnica, mas devido ao pequeno tamanho da amostra obtida, não foi possível correlacionar o seu uso com a utilização da medicação pós-operatória. Para os pacientes que se automedicaram previamente, não houve diferença significativa em relação à dor inicial. Quando os gêneros foram comparados, não foi possível observar uma diferença estatística significante entre eles com relação aos parâmetros estudados. Também foram descritos no trabalho os motivos de não inclusão dos 574 pacientes que foram abordados durante a realização deste estudo. Com base nos resultados, conclui-se que o cetorolaco diminuiu expressivamente o nível de dor durante a espera pelo atendimento, porém com relação ao tempo esperado pelo paciente para tomar a primeira dose de medicação pós-operatória, a última dose, a quantidade de comprimidos e a frequência de ingestão não demonstrou a mesma diferença. Também não houve diferença no nível de dor inicial entre os pacientes que se automedicaram e os que não fizeram uso dessa prática. Devido ao pequeno número da amostra, não foi possível encontrar uma correlação entre o uso da técnica anestésica intrapulpar e medicação pós-operatória, sugerindo mais estudos futuros.(AU)

The aim of this study was to evaluate the use of ketorolac tromethamine (10mg sublingual taken 30 minutes before pulpectomy in patients with irreversible pulpitis) in pain reduction immediately before the procedure and the 48 subsequent hours, postoperative consumption of analgesic drugs and time for its use. The influence of intrapulpal anesthesia, the use of analgesic self-medication prior to the demand for care and gender difference on the levels of pre- and postoperative pain was also evaluated. It was also proposed assess the need for antibiotic presence in the intracanal medicament, comparing Otosporin® with hydrocortisone. A total of 608 patients who presented to Dental Urgency Sector from Dental School of Bauru (USP) or Emergency Dental Sector from Bauru City Hall were invited to participate, and 34 completed properly planned protocol. They were distributed in 4 groups that received either ketorolac or placebo as preoperative medication and Otosporin® or hydrocortisone as intracanal medication. The rates of pain intensity were recorded by means of a visual analogue scale before pretreatment medication, immediately before the appointment, 1, 2, 4, 12, 24, 48 hours after the appointment, and when there was taken post medication for postoperative pain relief. It was also recorded if the patient had self medicated and which the drug used and, if there was need intrapulpal anesthesia, amount of ketorolac and rescue medication (paracetamol 750mg) consumed by the patient postoperative time and the waitng time for consumption. The results showed that patients receiving Ketorolac as preoperative medication had a significant reduction of pain in 30 minutes compared to placebo. It was observed that the time required for the intake of postoperative drug showed no significant difference between groups, as well as the amount of medication intake. The time elapsed between the first and last dose of postoperative medication also showed no statistical difference. Concerning intrapulpal anesthesia, 78% of patients required for this technique, but because of the small sample size obtained it was impossible to correlate their use with the use of postoperative medication. For patients who practiced self medication previously, there was no significant difference with respect to initial pain. When genders were compared, it was not possible to observe a statistically significant difference between them regarding the parameters studied. Were also described in the study the reasons of non-inclusion of 574 patients that were addressed during this study. Based on the results, it is concluded that ketorolac significantly decreased the level of pain during the waiting time, but with respect to the time length for the patient to take the first dose of postoperative medication, the last dose, the number of tablets and taken frequency did not show the same difference. There was no difference in the initial level of pain among patients who practiced self medication and those who did not use this practice. Due to the small sample size, it was not possible to find a correlation between the use of the anesthetic technique intrapulpal and postoperative medication, suggesting more future studies.(AU)

Evaluation of antinociceptive effect of pregabalin in mice and its combination with tramadol using tail flick test

The development of combination therapy is a coherent approach in severe pain treatment. The present study investigated the antinociceptive effect of pregabalin alone and in combination with tramadol in acute pain modeling. Therefore, three groups of male mice received either pregabalin [1 to 400 mg/Kg], tramadol [10 to 80 mg/Kg] or their combination intraperitoneally. Then latency time, maximum possible effect [%MPE] and area under curve [AUC] were calculated in tail flick test. The antinociceptive indexes were significantly increased in10, 100 and 200 mg/kg of pregabalin while tramadol showed dose-dependent antinociception [effective dose 50% was 54 to 79 mg/Kg]. The antinociceptive effect of 100 mg/Kg of pregabalin [%MPE = 35 +/- 4%] was similar to that of 50 mg/Kg of tramadol. The combination of non-analgesic doses [10 mg/Kg] of tramadol and pregabalin did not increase%MPE and AUC, but the co-administration of 30 mg/Kg of tramadol with pregabalin [10 mg/Kg] increased all antinociceptive indexes significantly compared to the controls and with each drug alone. In conclusion, pregabalin showed a comparable antinociceptive effect to tramadol. The increase in analgesic effect was observed after the combination of low analgesic doses of tramadol with pregabalin, while the combination of non-analgesic doses of each drug reversed the interaction to antagonism. Therefore to increase the analgesic effect in pain management, more attention should be paid to respecting right proportion of drug combination. Further studies that specify the mechanism[s] and statement of interaction are needed to expand these findings to clinical applications

Neurotoxicidade induzida por analgésicos: revisão de literatura / Analgesic-induced neurotoxicity: a literature review

Os analgésicos sistêmicos são considerados efetivos no tratamento de dor aguda e crônica. No entanto, a depender do estado do paciente, é necessário utilizar analgésicos que exercem efeito de modulação da dor no sistema nervoso central. A medula espinhal é um dos locais de escolha para realizar um controle da dor efetivo. Porém, o uso de analgésicos nesta via pode estar relacionado com a ocorrência de neurotoxicidade. Dentre os analgésicos utilizados para avaliação de neurotoxicidade, os opioides, os anestésicos locais, a cetamina e os anti-inflamatórios não esteroidais (AINES) são normalmente relatados. Alguns mecanismos moleculares envolvidos no processo de neurotoxicidade já foram relatados pela utilização destes fármacos. Apoptose, lesões oxidativas e alterações na neurogênese já foram descritas, porém os resultados ainda são controversos. Portanto, novas linhas de pesquisa devem ser conduzidas com o objetivo de avaliar o efeito neurotóxico de fármacos amplamente utilizados para o tratamento da dor.

Systemic analgesics are considered effective in treating acute and chronic pain. However, depending on the patient's condition, it is necessary to use analgesics that modulate pain in the central nervous system. The spinal cord is one of the places of choice to perform effective pain control. However, the use of analgesics along this path may be related to the occurrence of neurotoxicity. Among the drugs used to evaluate neurotoxicity, opioids, local anesthetics, ketamine and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly reported. Some molecular mechanisms involved in the neurotoxicity process have been reported with the use of these drugs. Apoptosis, oxidative lesions and neurogenesis changes have been described, although the results are still controversial. Therefore, new lines of research are necessaryin order to evaluate the neurotoxic effect of drugs widely used in pain treatment.

Lumiracoxib for acute postoperative dental pain: a systematic review of randomized clinical trials / Lumiracoxibe para dor dental aguda e pós-operatória: uma revisão sistemática de ensaios clínicos randomizados

CONTEXT AND OBJECTIVE: Lumiracoxib is an anti-inflammatory drug that has been used to treat acute dental pain, mainly in postsurgical settings, in which the greatest levels of pain and discomfort are experienced during the first 24 hours. This study aimed to assess the efficacy and safety of lumiracoxib for treating acute postsurgical dental pain. DESIGN AND SETTING: Systematic review developed at the Brazilian Cochrane Centre, Universidade Federal de São Paulo. METHODS: An electronic search was conducted in the PubMed, Cochrane Library, Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Electronic Library Online) and Embase databases. A manual search was also performed. Only randomized controlled trials were included, and these were selected and assessed by two researchers with regard to the risk of bias. RESULTS: Three clinical trials with 921 participants were included. Lumiracoxib 400 mg produced onset of analgesia in a shorter time than shown by lumiracoxib 100 mg, celecoxib 200 mg and ibuprofen 400 mg. There was no difference between lumiracoxib 400 mg and rofecoxib 50 mg. In two studies, the mean time taken to attain onset of analgesia for the placebo was not estimated because the number of participants who reached onset was too small. CONCLUSION: There is evidence with a moderate risk of bias that recommends the use of lumiracoxib for acute postoperative dental pain. However, the adverse effects are not completely known. Given that lumiracoxib is currently available in only three countries, further studies are likely to be rare and discouraged.

CONTEXTO E OBJETIVO: O lumiracoxibe é um anti-inflamatório que tem sido utilizado no tratamento de dor dental aguda, principalmente no cenário pós-cirúrgico, no qual níveis mais elevados de dor e desconforto são sentidos durante as primeiras 24 horas. Este estudo teve por objetivo avaliar a eficácia e a segurança do lumiracoxibe no tratamento da dor dental aguda e pós-operatória. TIPO DE ESTUDO E LOCAL: Revisão sistemática desenvolvida no Centro Cochrane do Brasil, Universidade Federal de São Paulo. MÉTODOS: Foi realizada busca eletrônica nas bases de dados PubMed, Cochrane Library, Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde), SciELO (Scientific Electronic Library Online) e Embase. Também foi realizada busca manual. Apenas ensaios clínicos randomizados foram incluídos e foram selecionados e avaliados por dois pesquisadores quanto ao risco de viés. RESULTADOS: Foram incluídos três ensaios clínicos com 921 participantes. O lumiracoxibe 400 mg mostrou menor tempo de início de analgesia que o lumiracoxibe 100 mg, celecoxibe 200 mg e ibuprofeno de 400 mg. Não houve diferença entre lumiracoxibe 400 mg e rofecoxibe 50 mg. Em dois estudos o tempo médio de início de analgesia para o placebo não foi estimado, pois o número de participantes que a alcançou foi pequeno. CONCLUSÃO: Há evidências, com moderado risco de viés, que recomendam o uso de lumiracoxibe para a dor dental aguda e pós-operatória. No entanto, os efeitos adversos não são completamente conhecidos. Considerando que o lumiracoxibe está disponível em apenas três países, provavelmente a realização de pesquisas futuras será rara e desestimulada.