Sufentanil during anesthetic induction of remifentanil-based total intravenous anesthesia: a randomized controlled trial / Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico

Abstract Background Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia. Methods Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery. Results The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48 h after surgery were -7.2 mg (95%CI: -12.5 to -2.1, p < 0.001), -3.9 mg (95%CI: -11.9 to 4.7, p = 0.26), -0.6 mg (95%CI: (-12.7 to 12.7, p = 0.80), and -1.8 mg (95%CI: (-11.6 to 15.6, p = 0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point. Conclusion Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.

Resumo Justificativa A dor pós-operatória é uma grande preocupação quando o remifentanil é usado para anestesia intravenosa total devido à sua meia-vida ultracurta. Os opioides de ação mais longa, como o sufentanil, têm sido usados durante a indução de anestesia intravenosa total à base de remifentanil como um meio de superar essa deficiência. Porém, a eficácia e segurança de tal estratégia ainda precisam de evidências advindas de ensaios clínicos randômicos. Portanto, objetivamos avaliar a eficácia analgésica e a segurança pós-operatória de uma dose única de sufentanil administrada durante a indução de anestesia intravenosa total à base de remifentanil. Métodos Quarenta pacientes eletivamente agendados para cirurgia abdominal aberta foram randomizados para receber anestesia intravenosa total à base de remifentanil, com ou sem uma dose única de sufentanil, após a indução da anestesia. Avaliamos o consumo de morfina no pós-operatório, administrado através de uma bomba de analgesia controlada pelo paciente. Os escores de dor autorrelatados e a ocorrência de náusea, vômito, prurido, agitação, sonolência e depressão respiratória também foram avaliados até dois dias após a cirurgia. Resultados A diferença média entre os grupos sufentanil e controle em relação ao consumo de morfina em sala de recuperação pós-anestesia e após 12, 24 e 48 horas da cirurgia foi de -7,2 mg (IC 95%: -12,5 a -2,1, p < 0,001), -3,9 mg (IC 95%: -11,9 a 4,7, p = 0,26), -0,6 mg (IC 95%: (-12,7 a 12,7, p = 0,80) e -1,8 mg (IC 95%: -11,6 para 15,6, p = 0,94), respectivamente. Não houve diferença significativa tanto nos escores de dor autorrelatados, quanto na incidência de eventos adversos entre os grupos. Conclusão Nossos achados sugerem que a administração de sufentanil durante a indução de anestesia intravenosa total à base de remifentanil está associada à redução do consumo de opioides no pós-operatório imediato.

The impact of patients controlled analgesia undergoing orthopedic surgery / O impacto da analgesia controlada pelos pacientes submetidos a cirurgias ortopédicas

ABSTRACT INTRODUCTION: The currently common musculoskeletal disorders have been increasingly treated surgically, and the pain can be a limiting factor in postoperative rehabilitation. RATIONALE: Patient controlled analgesia (PCA) controls pain, but its adverse effects can interfere with rehabilitation and in the patient discharge process. This study becomes important, since there are few studies evaluating this correlation. OBJECTIVES: To compare the outcomes of patients who used and did not use patient controlled analgesia in postoperative orthopedic surgery with respect to pain, unscheduled need for O2 (oxygen), and time of immobility and in-hospital length of stay. METHODS: This is an observational, prospective study conducted at Hospital Abreu Sodré from May to August 2012. The data was daily obtained through assessments and interviews of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), thoracolumbar spine arthrodesis (long PVA), cervical spine arthrodesis (cervical AVA) and lumbar spine arthrodesis (lumbar PVA). RESULTS: The study showed some differences between groups, namely: the painful level was higher in the group undergoing lumbar PVA without PCA compared with the group with PCA (p = 0.03) and in the group of long PVA without PCA in the early postoperative period. This latter group used O2 for a longer time (p = 0.09). CONCLUSION: In this study, PCA was useful for analgesia in patients undergoing lumbar PVA and probably would have influenced the usage time of O2 in the group of long PVA in face of a larger sample. The use of PCA did not influence the time of leaving the bed and the in-hospital length of stay for the patients studied.

RESUMO INTRODUÇÃO: As disfunções musculoesqueléticas, comuns atualmente, têm sido cada vez mais tratadas cirurgicamente e a dor é pode ser um fator limitante na reabilitação pós-operatória. JUSTIFICATIVA: A analgesia controlada pelo paciente (PCA) controla a dor, porém seus efeitos adversos podem interferir no processo de reabilitação e alta dos pacientes. Esta pesquisa torna-se importante, pois poucos estudos avaliam essa correlação. OBJETIVOS: Comparar a evolução dos pacientes que usaram e não usaram PCA no pós-operatório de cirurgias ortopédicas em relação à dor, à necessidade de O2 (oxigênio) não programada e ao tempo de imobilização e internação hospitalar. MÉTODOS: Estudo observacional, prospectivo, feito no Hospital da AACD de maio a agosto de 2012. Obtiveram-se dados diários por meio de avaliação e entrevista dos pacientes submetidos à artroplastia total de quadril (ATQ) e joelho (ATJ), artrodese de coluna toracolombar (AVP longa), coluna cervical (AVA cervical) e coluna lombar (AVP lombar). RESULTADOS: O estudo evidenciou algumas diferenças entre os grupos: o nível álgico foi maior no grupo submetido à AVP lombar sem PCA em relação ao com PCA (p = 0,03) e no grupo de AVP longa sem PCA no primeiro pós-operatório. Nesse último grupo, houve uso de O2 por mais tempo (p = 0,09). CONCLUSÃO: Neste estudo, a PCA mostrou-se útil para analgesia em pacientes submetidos à AVP lombar e provavelmente teria influência no tempo de uso de O2 no grupo de AVP longa caso a amostra fosse maior. O uso da PCA não influenciou no tempo de saída do leito e de internação hospitalar nos pacientes estudados.

Morphine sparing effect of proparacetamol in surgical and trauma intensive care

Safe and balanced analgesia is one of the corner stones in the management of critically ill patients. Patient controlled analgesia has proven to be one of the methods in achieving this goal. Combined analgesic regimes have been shown to improve pain therapy. The aim of our study is to evaluate efficacy and tolerability of morphine PCA, when used with mt ravenous proparacetamol in surgical and trauma intensive care patients. Forty-two patients were included in this prospective randomized study. Two patients were later excluded. Twenty patients received 2 grams proparacetamol every 6 hours and PCA morphine [proparacetamol and morphine group]. Another 20 patients received PCA morphine only [morphine group]. Each group had equal number of trauma and postoperative patients. Patients with head injury, liver trauma and allergy to paracetamol were excluded from the study. The total amount of morphine required for 24 hours and pain relief were evaluated. Tolerability was assessed by monitoring heart rate, blood pressure, respiratory rate, adverse effects, renal and hepatic parameters. The total morphine requirement in the proparacetamol and morphine group was significantly low [P<0.001]. Incidence of vomiting was also significantly lower in the proparacetamol and morphine group, this may be related to the amount of morphine consumption. There was no significant difference in renal and hepatic parameters. Using proparacetamol as adjuvant to patient controlled morphine analgesia, decreases total consumption and adverse effects of morphine in surgical and trauma intensive care patients