Oral administration of eucalyptol reduces cell migration and pain-like behavior in zymosan-induced arthritis mice

Abstract Rheumatoid arthritis (RA) is an inflammatory disease that utilizes nonbiologic and biologic drugs for appropriate disease management. However, high cost, adverse effects, reduced effectiveness, and risk of infection have stimulated the search for safer and more efficacious therapeutic strategies. In the present study, we aimed to evaluate the anti-inflammatory and analgesic properties of eucalyptol in an experimental model of arthritis. Mice were administered zymosan or saline intra-articularly. One hour before the zymosan administration, the mice were treated with oral eucalyptol (200-400 mg/kg) and vehicle. Cell influx, neutrophils, lymphocytes, and monocytes were measured in joint exudates. Joint pain was assessed using paw-pressure tests. Orally administered eucalyptol (200 and 400 mg/kg) significantly reduced cell influx, as well as neutrophils, lymphocytes, and monocytes, when compared with the control. Eucalyptol at a dose of 400 mg/kg significantly reversed joint pain and demonstrated analgesic activity (60%); however, 200 mg/kg failed to alter joint pain. These results indicate that oral eucalyptol promotes anti-inflammatory and analgesic activity in mice subjected to zymosan-induced arthritis.

Treatment of patients with neuropathic pain and provision of drug information by clinical pharmacists

Abstract Patient's satisfaction with healthcare services has an influence on pain management, which can be improved by patient education. Therefore, this study was aimed at identifying primary care health service opportunities in the treatment of neuropathic pain and assessing patients' satisfaction with the provision of drug information by clinical pharmacists. This was a cross- sectional, prospective study conducted at a pain unit during March-May 2017. Patients aged >18 years; diagnosed with neuropathic pain; and who used amitriptyline, gabapentin, pregabalin, or duloxetine were included. They were verbally informed about drug treatment by a clinical pharmacist, and their satisfaction was evaluated after 1 month. In all, 90 patients were included. The median duration for which the patients experienced pain until hospital admission was 3.6 years; furthermore, this duration was longer among women (p < 0.05). However, the median time to seeking advice from doctors was 3 months. The patients (15.6%) were less likely to admit pain unit initially and 46.7% had visited different units before being admitted to a pain unit. More than 95% of the patients indicated that they had received information from a pharmacist at a clinic and were satisfied with the provision of information (median duration, 8.5 min). Thus, the involvement of pharmacists in multidisciplinary pain management may help improve health- related outcomes at hospitals and/or in community care settings

Erding formula and bioactive markers in hyperuricemia: towards rational scientific approaches for the modernization of Traditional Chinese Medicine

Introduction: Traditional Chinese Medicine (TCM) represents one of the first holistic approaches in the world to treat and prevent disease. Herbal medicine is one of the major therapeutic remedy in TCM. It often involves multi-herb therapies instead of single herb preparations. Parallel to western medicine, hundreds of herbal formulas have been made available as finished products. Currently, the use of herbal products is popular as treatment option or to complement western medicine. Indications of the herbal formulas were established by TCM terms such as heat-clearing and/or detoxifying which lack modern pharmacological meanings. It is difficult for people without relevant background to understand such terms and their implications for treatments. Furthermore, due to the quality control issues of herbal medicines which contain multiple constituents, consumers may be confronted with the risk of using unstandardized products. Hence, in this thesis, the modernization of TCM is discussed through employing scientific pharmaceutical approaches to a traditional formula, called Erding formula (EF). The aim was to investigate if a new indication, hyperuricemia, can be assigned to a heat-clearing and detoxifying formula. Our hypothesis was: Can Erding formula be used for hyperuricemia treatment and is esculetin a bioactive marker for this new indication? Methods: A hypoxanthine and potassium oxonateinduced hyperuricemic mouse model, a xyleneinduced inflammatory mouse model, and an acetic acidinduced pain model were used to investigate EF and its constituent herbs. The quantity of esculetin was measured by high-performance liquid chromatography. The therapeutic effect of esculetin was assessed using potassium oxonate induced hyperuricemic mouse model, and esculetin and its metabolites were characterized in serum via ultra-performance liquid chromatographyquadrupole time-of-flight mass spectrometry. To develop a modern dosage form, a laboratory-scale wet bead milling approach was employed to prepare esculetin nanocrystals. The formulation was further optimized by design of experiment, and an optimized formulation was then characterized for its saturation solubility and short-term stability. Results: The study showed that EF and Viola yedoensis Makino (Viola) lowered uric acid (UA) levels, while EF and all four individual herbs had antiinflammatory and analgesic activities. These findings revealed that EF was able to treat hyperuricemia and suggested that Viola was the main herb in EF on reducing UA levels. The study showed that esculetin significantly reduced UA levels and six metabolites of esculetin were identified in serum. This confirms that esculetin was absorbed and is a suitable bioactive and quality control marker for EF in hyperuricemia treatment. An esculetin-Povacoat nanocrystal formulation with a 200 nm particle size was successfully prepared. The formulation presented up to a 1.5-fold increase in saturation solubility compared to the bulk esculetin and it was stable for 180 days. Conclusion: The studies proved that Erding formula can be used for hyperuricemia treatment with esculetin as bioactive quality control marker. As well, a new nano-sized formulation of the bioactive marker, esculetin, was created. This presented the possibility to develop an innovative nanotechnological product of the active substances derived from herbal medicine. The findings facilitated a better understanding of TCM terms and concept through mechanistic scientific experiments. This study revealed a potential pathway and an idea to modernize TCM without setting aside its unique concepts. This might increase the global acceptance of TCM products. Furthermore, the TCM concept might be useful in the development of multi-component drug products

Medicina Tradicional Chinesa (MTC) representa uma das primeiras abordagens holísticas em âmbito global para tratar e prevenir doenças. A fitoterapia consiste na principal terapia na MTC. Frequentemente, envolve terapias com múltiplas ervas em vez de preparações individuais. Paralelamente à medicina ocidental, centenas de fórmulas herbais foram disponibilizadas como produtos acabados. Atualmente, o uso de produtos fitoterápicos é popular como opção de tratamento ou para complementar a medicina ocidental. As indicações das fórmulas fitoterápicas foram estabelecidas pelos termos da MTC, tais como "limpeza pelo calor e / ou desintoxicante", que não têm significados farmacológicos modernos. É difícil para a população em geral e mesmo para profissionais sem histórico relevante na área entender tais termos e suas implicações para os tratamentos. Além disso, devido às questões de controle de qualidade dos medicamentos fitoterápicos que contêm múltiplos constituintes, os pacientes podem ser confrontados com o risco de usar produtos não padronizados. Assim, nessa tese, a modernização da MTC é discutida por meio da utilização de abordagens farmacêuticas científicas para uma fórmula tradicional, denominada fórmula de Erding (FE). O objetivo foi o de investigar se uma nova indicação, a hiperuricemia, pode ser atribuída a uma fórmula desintoxicante e de compensação de calor. Nossa hipótese foi: a fórmula de Erding pode ser usada para tratamento de hiperuricemia e a esculetina é um marcador bioativo para essa nova indicação? Foi empregado modelo de camundongo hiperuricêmico induzido por hipoxantina e oxonato de potássio, outro modelo de camundongo inflamatório induzido por xileno e, adicionalmente, modelo de dor induzida por ácido acético. Esses modelos foram usados para investigar a FE e suas ervas constituintes. A quantidade de esculetina foi determinada por cromatografia líquida de alta eficiência. O efeito terapêutico da esculetina foi avaliado utilizando modelo de camundongo hiperuricêmico induzido por oxonato de potássio, e a esculetina e seus metabólitos foram caracterizados no soro por cromatografia líquida de alto desempenho - espectrometria de massa. Para desenvolver forma farmacêutica moderna, uma abordagem de moagem em escala úmida reduzida foi empregada tendo em vista a preparação de nanocristais de esculetina. A formulação foi ainda otimizada empregado planejamento experimental. Essa fórmula foi caracterizada quanto à sua solubilidade de saturação e estabilidade a curto prazo. O estudo mostrou que a FE e a Viola yedoensis Makino (Viola) reduziram os níveis de ácido úrico (AU), enquanto a FE e as quatro plantas individuais apresentaram atividades antiinflamatória e analgésica. Esses resultados revelaram que a FE foi capaz de tratar a hiperuricemia e sugeriu que a viola foi a principal erva da FE na redução dos níveis de AU. O estudo mostrou também que a esculetina reduziu significativamente os níveis de AU e os seis metabólitos da esculetina foram identificados no soro. Tal resultado confirma que a esculetina foi absorvida e pode ser usada como marcador de controle bioativo e de qualidade para FE, no tratamento da hiperuricemia. A formulação de nanocristais de esculetin-povacoat® apresentou tamanho de partícula de 200 nm. A formulação apresentou aumento de 1,5 vezes na solubilidade de saturação em comparação com a esculetina em escala micrométrica e manteve-se estável durante 180 dias. Os estudos comprovaram que a fórmula de Erding pode ser utilizada no tratamento da hiperuricemia empregando a esculetina como marcador bioativo de controle de qualidade. Além disso, foi desenvolvida formulação inovadora, em escala nanométrica, do marcador bioativo, a esculetina. Esse resultado permitiu desenvolver produto com base nanotecnológica das substâncias ativas derivadas do fitoterápico, assim comol permitiram melhor compreensão dos termos e dos conceitos da MTC por meio de experimentos científicos mecanicistas. Esse estudo revelou potencial para a modernização da MTC sem excluir seus conceitos únicos. Isso pode aumentar a aceitação global dos produtos MTC. Além disso, o conceito de MTC pode ser útil no desenvolvimento de medicamentos de múltiplos componentes

Single-center, retrospective study on changes in pain-relieving therapy after bone metastasis detection by bone scintigraphy in prostate cancer patients

Abstract Whole-body bone scintigraphy (WB-BS) is used for detecting and monitoring metastatic spread of prostate cancer (PCa) and to investigate bone pain episodes. To investigate the impact of a positive WB-BS on pain-relieving medicine prescription in PCa patients, a single-center, retrospective cohort study with PCa patients classified as positive for bone metastases (BM) by WB-BS was conducted. Demographic, clinical, and ambulatory pain-relieving medicine prescription data were evaluated. Pain-relieving medicines were categorized according to the WHO 'Analgesic Ladder'. Regimens adopted before and after WB-BS were compared. Differences were considered significant at p<0.05. A total of 180 PCa patients were diagnosed with BM, 64.4% of whom were ≥65 years of age. Thirty-three patients were prescribed analgesics only after WB-BS, mostly including NSAIDs and weak opioids. Pain-relieving prescription changed after WB-BS in patients with prescriptions before and after WB-BS, with a reduction in NSAIDs and adjuvants and an increase in weak and strong opioids. In addition, 40% of patients with WHO analgesic step 1 drugs and 21.7% of patients with WHO step 2 drugs before WB-BS changed to other WHO steps after WB-BS. Pain-relieving prescriptions changed after a positive WB-BS, providing evidence that it could contribute to clinical management of painful metastatic PCa patients.

Importancia del anestesiólogo en la prevención del dolor crónico / Importance of the anesthesiologist in the prevention of chronic pain

The development of chronic pain after surgery or persistent postoperative pain is a significant public health problem that affects between 10%-56% of patients undergoing surgical intervention. It produces great restrictions of mobility, limitation of daily activities, dependence on opioids, anxiety, depression, a great alteration of the quality of life and important legal and medical-economic consequences. There is a very close correlation between acute postoperative pain, and persistent postoperative pain. For this reason, pain must be treated effectively in its acute phase to reduce the incidence of chronic pain after surgery. There are risk factors that predispose to its appearance and that must be known by the anesthesiologist. In an individualized and meticulous pre-anesthetic consultation, these risk factors can be detected, as well as the presence of surgical procedures related to chronic pain, with the purpose of the therapeutic approach of the first ones if necessary, and a good planning of the anesthetic and analgesic technique, which reduces the participation of the second, in the chronicity of acute pain. The role of the anesthesiologist in the pre-anesthetic consultation is essential for the planning of preventive and multimodal analgesia that, together with other resources, should reduce the incidence of persistent postoperative pain.

El desarrollo del dolor crónico después de la cirugía o dolor posoperatorio persistente, es un problema de salud pública significativo que afecta entre el 10%-56% de los pacientes sometidos a una intervención quirúrgica. Produce grandes restricciones de la movilidad, limitación de las actividades de vida diaria, dependencia a los opioides, ansiedad, depresión, una gran alteración de la calidad de vida e importantes consecuencias legales y médico-económicas. Hay una correlación muy estrecha entre el dolor agudo posoperatorio, y el dolor posoperatorio persistente. Por esa razón, el dolor debe ser tratado de manera eficaz en su fase aguda para disminuir la incidencia del dolor crónico posterior a la cirugía. Existen factores de riesgo que predisponen a su aparición y que deben ser conocidos por el anestesiólogo. En una consulta pre-anestésica individualizada y minuciosa, se podrán detectar estos factores de riesgo, como también la presencia de procedimientos quirúrgicos relacionados con el dolor crónico, con la finalidad del abordaje terapéutico de los primeros de ser necesario, y una buena planificación de la técnica anestésica y analgésica, que disminuya la participación de los segundos, en la cronicidad del dolor agudo. El rol del anestesiólogo en la consulta pre-anestésica, es fundamental para la planificación de la analgesia preventiva y multimodal que junto a otros recursos deberían disminuir la incidencia del dolor postoperatorio persistente.

Case report: Patient controlled analgesia after pediatric scoliosis surgery through erector spinal plane catheter / Analgesia controlada por paciente a través de catéter en plano erector espinal poscirugía escoliosis pediátrica

INTRODUCTION: Erector spinae plane block (ESPB) is a recently described technique (2016); its use as continuous analgesia with an intrafascial catheter in anterior scoliosis surgery for pediatric patients in intensive care unit (ICU) has not been reported in the literature. OBJECTIVE: To describe the use of an intrafascial catheter in the erector spinae for continuous infusion and patient-controlled analgesia as a postoperative analgesic technique in anterior scoliosis surgery. CLINICAL CASE: 15-year-old patient weighing 34 kg, diagnosed with scoliosis with 110° Cobb angle in the context of neurofibromatosis, subjected to anterior corrective surgery with continuous analgesia and patient-controlled analgesia through an intrafascial catheter in the erector spinae. CONCLUSIONS: The use of continuous intrafascial analgesia and patient-controlled analgesia in the erector spinae provided adequate analgesic control in the postoperative period of corrective anterior scoliosis surgery in a pediatric patient in ICU.

INTRODUCCIÓN: El bloqueo del plano del erector de la espina (ESPB) es una técnica de reciente descripción (2016). Su uso como analgesia continua con catéter intrafascial en cirugía de escoliosis por vía anterior para pacientes pediátricos en unidad de cuidados intensivos (UCI) no ha sido reportado en la literatura. OBJETIVO: Describir el uso del catéter intrafascial del erector de la espina como técnica analgésica posoperatoria en cirugía de escoliosis vía anterior con analgesia en infusión continua y controlada por el paciente. CASO CLÍNICO: Paciente de 15 años, peso 34 kg, con diagnóstico de escoliosis con ángulo de Cobb 110° en el contexto de neurofibromatosis, sometido a cirugía correctiva vía anterior con analgesia continua y controlada por el paciente mediante catéter intrafascial en erector de la espina en UCI. CONCLUSIONES: El uso de analgesia intrafascial continua y controlada por el paciente por catéter en el erector de la espina resulta en un adecuado control analgésico posoperatorio de cirugía correctiva de escoliosis via anterior en un paciente pediátrico en UCI.

Infusión intravenosa de ketamina a bajas dosis durante cirugía de artrodesis de columna. Una estrategia en el manejo del dolor agudo posoperatorio / Intravenous ketamine infusión at low doses during spinal arthodesis surgery. A strategy in acute postoperative pain management

INTRODUCTION: Acute postoperative pain is a complex problem given the pathophysiological characteristics, increasing health costs and complications and hindering recovery[1],[2]. Spinal arthrodesis is one of the most painful surgical procedures, presenting intense and disabling pain[3],[4]. Multimodal analgesia has been the tool with the best results, based on opioids; however, the combined use of drugs and dependence on opiates are important consequences. Therefore, the analgesic behavior during the use of subanesthetic doses of ketamine is described in the patients undergoing this procedure. METHODOLOGY: A prospective case series study was conducted from January-December 2019, with patients undergoing spinal arthrodesis who met the inclusion criteria, at the Hernando Moncaleano Perdomo University Hospital, Neiva. A univariate statistical analysis of all the variables is performed, with a joint interpretation of the results. RESULTS: A total of 17 patients underwent surgery, one of whom was excluded due to complications related to the surgical material. 88% of the patients showed evaluations of mild or absent pain in at least 4 times, with a number of morphine rescues in 24 hours of 1-2 per patient and patient ambulation in 90% on the first day. CONCLUSIONS. Postoperative spinal arthrodesis patients receiving intravenous ketamine infusion-based analgesia at subanesthetic doses showed mild or absent pain scores at almost all times.

INTRODUCCIÓN: El dolor agudo postoperatorio es un problema complejo dada las características fisiopatológicas, aumentando los costos en salud y las complicaciones y dificultando la recuperación[1],[2]. La artrodesis de columna, es uno de los procedimientos quirúrgicos más dolorosos, presentando un dolor intenso e incapacitante[3],[4]. La analgesia multimodal ha sido la herramienta con mejores resultados, tomando como base los opioides; sin embargo, el uso combinado de fármacos y la dependencia a opiáceos son consecuencias importantes. Por lo anterior, se describe el comportamiento analgésico durante el uso de dosis subanestésicas de ketamina en los pacientes llevados a dicho procedimiento. METODOLOGÍA: Se realiza un estudio tipo serie de casos, prospectivo de enero-diciembre de 2019, con los pacientes llevados a artrodesis de columna que cumplieron con los criterios de inclusión en el Hospital Universitario Hernando Moncaleano Perdomo, Neiva. Se realiza un análisis estadístico univariado de la totalidad de las variables, con una interpretación conjunta de los resultados. RESULTADOS: Se intervinieron un total de 17 pacientes, uno de los cuales fue excluido por complicaciones relacionadas con el material quirúrgico. El 88% de los pacientes mostraron valoraciones de dolor leve o ausente en al menos 4 tiempos, con número de rescates de morfina en 24 h de 1-2 por paciente y deambulación de los pacientes en el 90% en el primer día. CONCLUSIONES: Los pacientes posoperatorios de artrodesis de columna que recibieron analgesia basada en infusión endovenosa de ketamina a dosis subanestésicas mostraron valoraciones de dolor leve o ausente, en casi todos los tiempos.

Consideraciones en pacientes con dolor crónico sometidos a cirugía / Considerations in chronic pain patients that will undergo surgery

Resumen El dolor crónico es una condición cada vez más prevalente, que afecta aproximadamente a un 32% de la población nacional. Estos pacientes poseen características particulares que complejizan un óptimo cuidado perioperatorio, sobre todo en términos de analgesia, efectos adversos de los distintos fármacos y complicaciones postquirúrgicas. El objetivo de esta revisión es exponer el creciente problema que involucra el manejo de los pacientes con dolor crónico no oncológico sometidos a una cirugía, y destacar algunas consideraciones que se deben tener en su cuidado. Dentro de los aspectos más relevantes están una adecuada caracterización del dolor y un buen esquema analgésico a ser utilizado en el perioperatorio, prefiriendo un enfoque multimodal ajustado acorde a las necesidades del paciente. Se debe tener especial consideración en pacientes usuarios crónicos de opioides, aquellos con dolor neuropático y aquellos con fibromialgia. Un adecuado seguimiento de estos grupos permitirá ajustar los esquemas de acuerdo con sus necesidades y lograr un mejor manejo analgésico perioperatorio.

Chronic pain is an increasingly prevalent condition, estimated in approximately 32% of the Chilean population. These patients have characteristics that make optimal perioperative care more complex, especially in terms of analgesia, adverse effects of the different drugs, and post-surgical complications. The aim of this publication is to expose the growing problem involved in the management of patients with chronic pain undergoing surgery, and to highlight some considerations that must be taken. Among the most relevant aspects are an adequate characterization of pain and a good analgesic scheme to be used in the perioperative period, preferring a multimodal analgesia approach adjusted according to the patient's needs. Special consideration should be given to patients with chronic opioids use, those with neuropathic pain and those with fibromyalgia. An adequate follow-up of these groups will allow adjusting the schemes according to their needs and achieve a better perioperative analgesic management.

Propofol-ketamine versus dexmedetomidine-ketamine for sedation during upper gastrointestinal endoscopy in pediatric patients: a randomized clinical trial / Propofol­cetamina versus dexmedetomidina­cetamina para sedação durante endoscopia digestiva alta em pacientes pediátricos: estudo clínico randomizado

Abstract Background and objectives Day-case pediatric sedation is challenging. Dexmedetomidine is a sedative analgesic that does not induce respiratory depression. We compared dexmedetomidine to propofol when it was added to ketamine for sedation during pediatric endoscopy, regarding recovery time and hemodynamic changes. Methods We enrolled 120 patients (2−7 years in age) and randomly assigned them into two groups. Each patient received intravenous (IV) ketamine at a dose of 1 mg.kg-1 in addition to either propofol (1 mg.kg-1) or dexmedetomidine (0.5 µg.kg-1). The recovery time was compared. Hemodynamics, oxygen saturation, need for additional doses, postoperative complications and endoscopist satisfaction were monitored. Results There was no significant difference in hemodynamics between the groups. The Propofol-Ketamine (P-K) group showed significantly shorter recovery times than the Dexmedetomidine-Ketamine (D-K) group (21.25 and 29.75 minutes, respectively, p < 0.001). The P-K group showed more oxygen desaturation. Eleven and 6 patients experienced SpO2 < 92% in groups P-K and D-K, respectively. A significant difference was noted regarding the need for additional doses; 10% of patients in the D-K group needed one extra dose, and 5% needed two extra doses, compared to 25% and 20% in the P-K group, respectively (p = 0.001). The P-K group showed less post-procedure nausea and vomiting. No statistically significant difference between both groups regarding endoscopist satisfaction. Conclusions The P-K combination was associated with a shorter recovery time in pediatric upper gastrointestinal endoscopy, while the D-K combination showed less need for additional doses. Registration number Clinical trials.gov (NCT02863861).

Resumo Justificativa e objetivos A sedação ambulatorial pediátrica é um desafio. A dexmedetomidina é um analgésico sedativo que não induz à depressão respiratória. Comparamos a dexmedetomidina ao propofol quando associados à cetamina para sedação durante endoscopia pediátrica, quanto ao tempo de recuperação e às alterações hemodinâmicas. Métodos Foram recrutados 120 pacientes (2−7 anos de idade) que foram aleatoriamente alocados em dois grupos. Cada paciente recebeu cetamina IV na dose de 1 mg.kg‐1, além de propofol (1 mg.kg‐1) ou dexmedetomidina (0,5 µg.kg‐1). Comparamos o tempo de recuperação. A hemodinâmica, saturação de oxigênio, necessidade de doses adicionais, complicações pós‐operatórias e satisfação do endoscopista foram monitoradas. Resultados Não houve diferença significante entre os grupos no que diz respeito à hemodinâmica. O grupo Propofol‐Cetamina (P‐C) apresentou tempos de recuperação significantemente mais curtos do que o grupo Dexmedetomidina‐Cetamina (D‐C) (21,25 e 29,75 minutos respectivamente, p < 0,001). Observou‐se frequência maior de dessaturação de oxigênio no grupo P‐C. Onze e 6 pacientes apresentaram SpO2 < 92% nos grupos P‐C e D‐C, respectivamente. Uma diferença significante foi observada em relação à necessidade de doses adicionais; 10% dos pacientes no grupo D‐C precisaram de uma dose extra e 5% precisaram de duas doses extras, em comparação com 25% e 20% no grupo P‐C, respectivamente (p = 0,001). O grupo P‐C apresentou menos náuseas e vômitos após o procedimento. Não houve diferença estatisticamente significante entre os dois grupos em relação à satisfação do endoscopista. Conclusões A combinação P‐C foi associada a tempo mais curto de recuperação na endoscopia digestiva alta pediátrica, enquanto a combinação D‐C mostrou menor necessidade de doses adicionais. Número de registro Clinical trials.gov (NCT02863861).

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Abstract Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo (p < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Analgesia preventiva con microdosis de ketamina en pacientes operados con anestesia general / Preemtive analgesia with micro doses of ketamine in patients under general anesthesia

INTRODUCTION: Acute postoperative pain is a complex physiological reaction to tissue injury or disease. Ketamine, an NMDA receptor antagonist, is the only intravenous anesthetic with hypnotic, analgesic and amnesic properties. OBJECTIVE: To evaluate the effectiveness of the administration of ketamine microdosis in patients operated with general anesthesia. METHODS: A prospective, quasi-experimental, controlled, double-blind study was conducted in patients operated under general anesthesia by the General Surgery service at the University Carlos Carlos de Céspedes University Hospital in Bayamo, in the period from January 2016 to December 2018. RESULTS: Age was homogeneous in both groups. The female sex prevailed in both groups without significant differences. There is a similarity in the mean ENV scores in the study group throughout the entire follow-up, never reaching 2 points. On the contrary, the patients in the control group, obtained throughout the follow-up an average score around 3 points. A lower opioid demand is observed in the group to which the ketamine microdose was administered. Hemodynamic parameters (heart rate, systolic and diastolic blood pressure) remained stable throughout the study period without statistically significant differences between the two. CONCLUSIONS: The administration of ketamine microdosis, as preventive analgesia in patients operated with general anesthesia, has proven effective in the control of acute postoperative pain.

INTRODUCCIÓN: El dolor postoperatorio agudo es una reacción fisiológica compleja a la lesión tisular o enfermedad. La ketamina, antagonista del receptor NMDA, es el único anestésico intravenoso con propiedades hipnóticas, analgésicas y amnésicas. OBJETIVO: Evaluar la efectividad de la administración de microdosis de ketamina en pacientes operados con anestesia general. MÉTODOS: Se realizó un estudio prospectivo, cuasi experimental, controlado, doble ciego en pacientes operados con anestesia general por el Servicio de Cirugía General en el Hospital Provincial Universitario "Carlos Manuel de Céspedes" de Bayamo, en el período comprendido desde enero de 2016 hasta diciembre de 2018. RESULTADOS: La edad fue homogénea en ambos grupos. El sexo femenino predominó en ambos grupos sin diferencias significativas. Hay una similitud en las puntuaciones medias de la ENV en el grupo estudio a lo largo de todo el seguimiento, nunca llegando a los 2 puntos. Por el contrario, los pacientes del grupo control, obtuvieron a lo largo de todo el seguimiento una puntuación media en torno a los 3 puntos. Se observa una demanda de opioide inferior en el grupo al que se le administró la microdosis de ketamina. Los parámetros hemodinámicos (frecuencia cardíaca, presión arterial sistólica y diastólica) permanecieron estables durante todo el periodo de estudio sin diferencias estadísticamente significativas entre ambos. CONCLUSIONES: La administración de microdosis de ketamina, como analgesia preventiva en pacientes operados con anestesia general, ha demostrado ser efectiva en el control del dolor agudo postoperatorio.

Complete essential oils of Laurus nobilisinducing antinociceptiveaction by opioid mechanism in C-Reflex and spinal Wind-Up model in rat / Aceites esenciales totales de Laurus nobilis inducen acción antinociceptivamediante mecanismo opioide en el modelode Reflejo-C y Wind-Up espinal en ratas

The essential oil of Laurus nobilis L. was used to test their antinociceptive efficacy. It was applied intraperitoneally (i.p.) to rats subjected to a nociception test (C reflex and spinal wind-up). The results showed that the essential oil applied at higher doses (0.06 mg/Kg) causes a complete abolition of the spinal wind-up, while the C reflex was unchanged, indicating a clear antinociceptive effect. At lower concentrations (0.012 mg/Kg), there was a lowering in the wind-up by 85% within ten minutes of the essential i.p. oil application. Interestingly, there was an effect of naloxone (0.08 mg/Kg i.p.) When applied, a change occurs that almost entirely reversed the antinociception caused by the essential oil from Laurus nobilis. We conclude that there is a significant antinociceptive effect of the essential oil of Laurus nobilis subjected to electric nociception. In addition, it was observed that naloxone reversed the antinociceptive effect (wind-up) produced by Laurus nobilis.

El aceite esencial de Laurus nobilis L. se usó para probar su eficacia antinociceptiva. Se aplicó por vía intraperitoneal (i.p.) a ratas sometidas a una prueba de nocicepción (reflejo-C y wind-up espinal). Los resultados mostraron que el aceite esencial aplicado a dosis más altas (0.06 mg/Kg) abolió completamente el wind-up espinal, mientras que el reflejo-C no cambió, lo que indica un claro efecto antinociceptivo. A concentraciones más bajas (0.012 mg/Kg), hubo una disminución en el wind-up en un 85% dentro de los diez minutos del i.p. la aplicación del aceite esencial. Curiosamente, hubo un efecto de la naloxona (0.08 mg/Kg i.p.) la cual revierte casi por completo la antinocicepción causada por el aceite esencial de Laurus nobilis. Concluimos que existe un efecto antinociceptivo significativo del aceite esencial de Laurus nobilis sometido a nocicepción eléctrica. Además, se observó que la naloxona revirtió el efecto antinociceptivo (wind-up) producido por Laurus nobilis.

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

The prophylactic effect of intravenous magnesium infusion on postoperative sore throat after thyroid surgery. A randomized clinical trial / Efecto profiláctico de la infusión de magnesio en dolor de garganta postoperatorio luego de una tiroidectomía. Un ensayo clínico aleatorizado

BACKGROUND: The reported incidence of postoperative sore throat (POST) varies widely from 14.4 to 100% with maximum severity at 4th to 6th postoperative hour. Nonetheless, it has increasingly become a common clinical problem particularly in thyroid surgery. Although POST usually resolves spontaneously in few days, it is likely to be the most common complaint. OBJECTIVES: Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the effectiveness of perioperative magnesium infusion in attenuating POST after thyroidectomy. METHODS AND MATERIAL: 80 female patients undergoing thyroid surgery, were preoperatively randomized into one of 2 groups. The magnesium group received magnesium sulfate (30 mg/kg) in 100 ml of isotonic saline over 15 min before induction of anesthesia, followed by a continuous magnesium sulfate infusion (10 mg/kg/h) for the duration of the operation. The control group received the same volume and rate of isotonic saline. RESULTS: This study showed that perioperative magnesium infusion had significantly reduced the overall incidence and severity of POST. The incidence of POST at rest (patients who recorded non-zero POST score after thyroid surgery) in the control group was 75% while the incidence of POST in magnesium group was 37.5% which is lower and that was highly significance. Higher sedation scores were encoun tered on arrival to PACU in Magnesium group when compared to controls. CONCLUSIONS: We concluded that perioperative magnesium sulphate infusion effectively decreased overall POST incidence and severity after thyroidectomy with better hemodynamic stability, albeit higher risk of post operative sedation.

La incidencia reportada de dolor de garganta postoperatorio (POST) varía ampliamente de 14,4 a 100% con severidad máxima en la 4ta a 6ta hora postoperatoria. Sin embargo, se ha convertido cada vez más en un problema clínico común, particularmente en la cirugía de tiroides. Aunque la POST generalmente se resuelve espontáneamente en pocos días, es probable que sea la queja más común. OBJETIVOS: Impulsado por el mayor número de pacientes con dolor de garganta después de la intubación después de la cirugía de tiroides, el objetivo del presente estudio fue evaluar la efectividad de la infusión perioperatoria de magnesio para atenuar la POST después de la tiroidectomía. MÉTODOS Y METERIAL: 80 pacientes mujeres sometidas a cirugía de tiroides, fueron asignadas al azar preoperatoriamente en uno de los 2 grupos. El grupo de magnesio recibió sulfato de magnesio (30 mg/kg) en 100 ml de solución salina isotónica durante 15 minutos antes de la inducción de la anestesia, seguido de una infusión continua de sulfato de magnesio (10 mg/kg/h) durante la operación. El grupo control recibió el mismo volumen y tasa de solución salina isotónica. RESULTADOS: Este estudio mostró que la infusión perioperatoria de magnesio había reducido significativamente la incidencia general y la gravedad de la POST. La incidencia de POST en reposo (pacientes que registraron una puntuación POST distinta de cero después de la cirugía de tiroides) en el grupo de control fue del 75%, mientras que la incidencia de POST en el grupo de magnesio fue del 37,5%, que es menor y de gran importancia. Se encontraron puntajes de sedación más altos al llegar a la UCPA en el grupo Magnesio en comparación con los controles. CONCLUSIONES: Llegamos a la conclusión de que la infusión perioperatoria de sulfato de magnesio disminuyó efectivamente la incidencia general de POST y la gravedad después de la tiroidectomía con una mejor estabilidad hemodinámica, aunque un mayor riesgo de sedación postoperatoria.

Prevalence of delirium in intensive care patients and association with sedoanalgesia, severity and mortality / Prevalencia de delirio en pacientes de cuidados intensivos y asociación con la sedoanalgesia, gravedad y mortalidad / Prevalência de delirium em pacientes de terapia intensiva e associação com sedoanalgesia, gravidade e mortalidade

ABSTRACT Objective: To establish the prevalence of delirium and its subsyndrome in intensive care and to associate it with the use of sedative and analgesia, severity and mortality. Method: Carried out in two intensive care units of adult patients, this is a quantitative and transversal study, with 157 patients, using the Richmond Agitation-Sedation Scale to assess the level of sedation and the Intensive Care Delirium Screening Checklist for delirium. The T test and Chi-square test were applied for statistical analysis. Results: The prevalence of delirium was 22.3%, and 49.7% of the subsyndrome. Associations of the use of midazolam with the presence of delirium (p=0.05) and subsyndromal delirium (p<0.01), use of clonidine with the appearance of delirium (p<0.01) and of fentanyl with subsyndromal delirium (p=0.09). There were no significant differences between the mortality of patients with delirium (p=0.40) and subsyndromal delirium (p=0.86), as well as association with the mortality score. Conclusion: The use of sedoanalgesia is associated with the presence of delirium and subsyndromal delirium. No significant statistical associations were found between the severity and mortality scores.

RESUMEN Objetivo: Establecer la prevalencia del delirio y su subsíndrome en pacientes de cuidados intensivos y asociarlos con el uso de la sedoanalgesia, con la gravedad y con la mortalidad. Método: Realizado en dos unidades de cuidados intensivos de pacientes adultos, se trata de un estudio cuantitativo y transversal, con 157 pacientes, utilizando las escalas Richmond Agitation-Sedation Scale (Escala de agitación-sedación de Richmond) para evaluar el nivel de sedación y la de la Intensive Care Delirium Screening Checklist (Lista de verificación para la detección del delirio en cuidados intensivos) para el delirio. Se aplicaron las pruebas de T y Chi-cuadrado para el análisis estadístico. Resultados: La prevalencia del delirio fue del 22,3%, y la del subsíndrome fue del 49,7%. Se han encontrado asociaciones del uso de midazolan con la presencia de delirio (p = 0,05) y del deilirio subsindromático (p < 0,01), del uso de clonidina con la aparición de delirio (p < 0,01) y de fentanil con el delirio subsindromático (p = 0,09). No se registraron diferencias significativas entre la mortalidad de los pacientes con delirio (p = 0,40) y el delirio. Conclusión: El uso de sedoanalgesia se asocia con la presencia de delirio y delirio subsindromático. No se encontraron asociaciones estadísticas significativas entre la gravedad y las puntuaciones de mortalidad.

RESUMO Objetivo: Estabelecer a prevalência do delirium e sua subsíndrome em pacientes de terapia intensiva e associar com uso de sedoanalgesia, gravidade e mortalidade. Método: Realizado em duas Unidades de Terapia Intensiva de pacientes adultos, trata-se de estudo quantitativo e transversal, com 157 pacientes, utilizando as escalas Richmond Agitation-Sedation Scale para avaliação do nível de sedação e Intensive Care Delirium Screening Checklist para delirium. Foi aplicado o teste t e qui-quadrado para análise estatística. Resultados: A prevalência de delirium foi 22,3% e da subsíndrome 49,7%. Foram encontradas associações do uso de midazolan com a presença de delirium (p=0,05) e delirium subsindromático (p<0,01), uso de clonidina com o aparecimento de delirium (p<0,01) e de fentanil com o delirium subsindromático (p=0,09). Não houve diferenças significativas entre mortalidade de paciente com delirium (p=0,40) e delirium subsindromático (p= 0,86), bem como associação com o escore de mortalidade. Conclusão: O uso de sedoanalgesia está associado à presenta de delirium e delirium subsindromático. Não foram encontradas associações estatísticas significativas entre os escores de gravidade e mortalidade.

The use of analgesics and risk of self-medication in an urban population sample: cross-sectional study / Uso de analgésicos e o risco da automedicação em amostra de população urbana: estudo transversal

Abstract Background and objectives: There are few data in the literature characterizing the pattern of analgesic use in Latin American countries, including Brazil. Little is known about the undertreatment of pain and its influence on the habit of self-medication with analgesics. The aim of this study is to define the pattern of analgesic use among chronic pain patients and its potential association with self-medication with analgesics. Method: Cross-sectional observational study with an urban population sample. Chronic pain was defined as a pain lasting for at least 90 days. The study was approved by the Research Ethics Committee of the institution. Results: 416 subjects were included; 45.7 % (n = 190) had chronic pain, with females (72.3 %; p = 0.04) being the most affected. Self-medication with analgesics is practiced by 78.4% of patients with chronic pain. The most common current analgesic treatment consists of non-steroidal anti-inflammatory drugs (dipyrone and acetaminophen). Weak opioids are rarely used and only 2.6% of subjects with chronic pain were taking these analgesics. None of the subjects were taking potent opioids. Conclusions: The practice of self-medication with analgesics is frequent among patients with chronic pain, which may be due to the underprescription of more potent analgesics, such as opioids. It can also be said that, given the data presented, there is no crisis of recreational opioid use in the studied population.

Resumo Justificativa e objetivos: Há poucos dados na literatura que caracterizam o padrão de uso de analgésicos na América Latina e no Brasil. Também se sabe pouco sobre o subtratamento da dor e sua influência no hábito de automedicação analgésica. O objetivo desta pesquisa é definir o padrão de uso de analgésicos entre os portadores de dor crônica (DC) e a sua potencial associação à automedicação analgésica. Método: Estudo observacional transversal com amostra de população urbana. A dor crônica foi definida como aquela presente por pelo menos 90 dias. A pesquisa foi aprovada pelo Comitê de Ética em Pesquisa institucional. Resultados: Foram incluídos 416 indivíduos; 45,7% (n = 190) portadores de dor crônica, sendo os do sexo feminino (72,3%; p = 0,04) os mais acometidos. A automedicação analgésica é praticada por 78,4% dos portadores de dor crônica. O tratamento analgésico vigente mais frequente é composto pelos anti-inflamatórios não esteroides (AINES), dipirona e paracetamol. Os opioides fracos são pouco usados e apenas 2,6% dos indivíduos com dor crônica fazem uso desses analgésicos. Nenhum dos indivíduos estava em uso de opioides potentes. Conclusões: A prática de automedicação analgésica é frequente entre os portadores de dor crônica, o que pode ser consequência da pouca prescrição de analgésicos mais potentes, como os opioides. Pode-se também dizer que, pelos dados apresentados, não ocorre uma crise de uso recreativo de opioides na população estudada.

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

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

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

Preemptive nebulized ketamine for pain control after tonsillectomy in children: randomized controlled trial / Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

Abstract Objectives The administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg-1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg-1) and saline placebo. Methods One hundred children aged (7-12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg-1 (Group K-IV), Nebulized Ketamine 1 mg.kg-1 (Group K-N1) or 2 mg.kg-1 (Group K-N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative. Results The mean time to first request for rescue analgesics was prolonged in K-N1 (400.9 ± 60.5 min, 95% CI 375.9-425.87) and K-N2 (455.5 ± 44.6 min, 95% CI 437.1-473.9) groups compared with Group K-IV (318.5 ± 86.1 min, 95% CI 282.9-354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5-77.1; p < 0.001), with a significant difference between K-N1 and K-N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K-IV (672.6 ± 272.8 mg, 95% CI 559.9-785.2), Group K-N1 (715.6 ± 103.2 mg, 95% CI 590.4-840.8) and Group K-N2 (696.6 ± 133.3 mg, 95% CI 558.8-834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8-1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K-IV, K-N1 or K-N2 group and without significant adverse effects. Conclusion Preemptive nebulized ketamine was effective for post-tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.

Resumo Objetivos A administração de cetamina por via inalatória através de nebulizador é relativamente nova e os estudos sobre este assunto são escassos. Nosso objetivo foi investigar a eficácia analgésica da cetamina nebulizada (1 e 2 mg.kg-1) administrada 30 minutos antes da anestesia geral em crianças submetidas à amigdalectomia eletiva, em comparação com cetamina intravenosa (0,5 mg.kg-1) e placebo (soro fisiológico). Métodos Cem crianças entre 7-12 anos foram randomicamente alocadas em quatro grupos (n = 25) e receberam: soro fisiológico para controle (Grupo C); 0,5 mg.kg-1 de cetamina intravenosa (Grupo C-IV); 1 mg.kg-1 de cetamina nebulizada (Grupo C-N1); 2 mg.kg-1 de cetamina nebulizada (Grupo C-N2). O desfecho primário foi o consumo total de analgésicos de resgate nas primeiras 24 horas de pós-operatório. Resultados O tempo médio para a primeira solicitação de analgésicos de resgate foi prolongado nos grupos C-N1 (400,9 ± 60,5 min, IC 95% 375,9-425,87) e C-N2 (455,5 ± 44,6 min, IC 95% 437,1-473,9) em comparação com o Grupo C-IV (318,5 ± 86,1 min, IC 95% 282,9-354,1) e o Grupo C (68,3 ± 21,9 min, IC 95% 59,5-77,1; p < 0,001), com uma diferença significativa entre os grupos C-N1 e C-N2 (p < 0,001). O consumo total de paracetamol IV nas primeiras 24 horas de pós-operatório foi reduzido no Grupo C-IV (672,6 ± 272,8 mg, IC 95% 559,9-785,2), Grupo C-N1 (715,6 ± 103,2 mg, IC 95% 590,4-840,8) e Grupo C-N2 (696,6 ± 133,3 mg, IC 95% 558,8-834,4) em comparação com o Grupo C (1153,8 ± 312,4 mg, IC 95% 1024,8-1282,8; p < 0,001). Não houve diferença entre os grupos de cetamina intravenosa e nebulizada (p = 0,312). Os pacientes dos grupos de cetamina intravenosa e nebulizada apresentaram escores VRS pós-operatórios menores, em comparação com o Grupo C (p < 0,001), sem diferenças entre os grupos C-IV, C-N1 ou C-N2 e sem efeitos adversos significativos. Conclusão A administração preventiva de cetamina nebulizada foi eficaz no alívio da dor pós-amigdalectomia. Cetamina nebulizada pode ser considerada como uma via alternativa eficaz à cetamina IV.

Trends in hospital consumption of analgesics after the implementation of a pain performance improvement plan / Tendências no consumo hospitalar de analgésicos após a implantação de plano de melhoria do controle da dor

Abstract Background: Pain management committee established a pain performance improvement plan in 2012. Objectives: The aim of the study was to assess the trends in analgesic consumption in a tertiary teaching hospital and the associated economic impact. Methods: A descriptive, retrospective study was conducted between 2011 and 2015. The analysis included: anti-inflammatory and antirheumatic products non-steroids, opioid analgesics and other analgesics and antipyretics. Data are converted into DDD/100 bed-days to analyze consumption trends. Main outcome measure: assessment of the analgesic consumption after the implementation of a pain performance improvement plan. Results: Overall, non-steroidal anti-inflammatory and antirheumatic products consumption decreased in 24.8 DDD/100 bed-days (-28.3%), accounting for most of the total analgesic consumption decrease (-13%) and total cost (-44.3%). Opioid consumption increased markedly from 22.3 DDD/100 bed-days in 2011 to 26.5 DDD/100 bed-days in 2015 (+18.9%). In 2011, the most consumed opioid was morphine (8.6 DDD/100 bed-days). However, there was an increasing trend in fentanyl consumption (from 8.1 to 12.1 DDD/100 bed-days in 2015), which resulted in fentanyl replacing morphine from the most consumed opioid in 2015 (12.1 DDD/100 bed-days). In 2015, the group of other analgesics and antipyretics represented 46.2% of the total analgesic consumption. Acetaminophen was the most commonly consumed analgesic drug (53.2 DDD/100 bed-days in 2015) and had the highest total cost, it represented 55.4% of the overall cost in 2015. Conclusion: Opioid consumption showed an increasing trend during the 5 year period, with fentanyl replacing morphine as the most used opioid. In general, analgesics diminished use was due to the decreasing trend of consumption of non-steroidal anti-inflammatory and antirheumatic products.

Resumo Justificativa: A Comissão para o Manejo da Dor estabeleceu um plano de melhoria no controle da dor em 2012. Objetivo: Avaliar as tendências do consumo de analgésicos em um hospital de ensino terciário e o impacto econômico associado. Métodos: Estudo descritivo, retrospectivo, feito entre 2011 e 2015. A análise incluiu: produtos anti-inflamatórios e antirreumáticos não esteroides, analgésicos opioides e outros analgésicos e antipiréticos. Os dados foram convertidos em DDD/100 leitos-dia para analisar as tendências de consumo. Principal medida do desfecho: avaliação do consumo de analgésicos após o estabelecimento de um plano de melhoria no controle da dor. Resultados: O consumo total de produtos anti-inflamatórios e antirreumáticos não esteroides diminuiu em 24,8 DDD/100 leitos-dia (-28,3%), representando a maior parte da redução total do consumo de analgésicos (-13%) e o custo total (-44,3%). O consumo global de opioides aumentou acentuadamente de 22,3 DDD/100 leitos-dia em 2011 para 26,5 DDD/100 leitos-dia em 2015 (+18,9%). Em 2011, o opioide mais consumido foi a morfina (8,6 DDD/100 leitos-dia). No entanto, houve uma tendência crescente no consumo de fentanil (de 8,1 para 12,1 DDD/100 leitos-dia em 2015), o que resultou na substituição de morfina por fentanil como o opioide mais consumido em 2015 (12,1 DDD/100 leitos-dia). Em 2015, o grupo dos outros analgésicos e antipiréticos representou 46,2% do consumo total de analgésicos. Acetaminofeno foi o analgésico mais consumido (53,2 DDD/100 leitos-dia em 2015) e teve o maior custo total, representou 55,4% do custo total em 2015. Conclusão: O consumo de opioides mostrou uma tendência crescente durante o período de cinco anos, fentanil substituiu morfina como o opioide mais usado. Em geral, o uso diminuído de analgésicos foi devido à tendência decrescente do consumo de produtos anti-inflamatórios e antirreumáticos não esteroides.