Eficacia de la analgesia peridural continua con bupivacaína y fentanilo en la cirugía de colon / Efficacy of continuous peridural analgesia with bupivacaine and fentanyl in colon surgery

Introducción: En la cirugía de colon se persigue lograr una recuperación acelerada y se debate el método analgésico más ventajoso. Objetivo: Comparar la eficacia analgésica de la infusión continua peridural con bupivacaína y fentanilo frente a la analgesia parenteral en este tipo de intervención. Métodos: Se realizó un estudio cuasi-experimental, prospectivo y longitudinal, en 30 pacientes operados de colon entre agosto 2018 agosto 2019 en el Hospital Militar Central Dr. Carlos J. Finlay; divididos de forma no aleatoria en grupo analgesia peridural y grupo analgesia multimodal endovenosa. Resultados: La demora en despertar y extubar en el grupo peridural fue inferior (1,6-1,8 min) a los 4,9-5,0 min en el multimodal, igual ocurrió con la estadía en Unidad Cuidados Intensivos Quirúrgicos y hospitalaria aunque con discreta diferencia. El 60 por ciento de los pacientes en el grupo peridural presentaron ruidos hidroaéreos en las primeras 24 h y el 80 por ciento expulsó gases a las 48 h o antes, con marcada diferencia del multimodal. La analgesia fue buena en ambos grupos, valores de escala visual análoga inferiores en el grupo peridural, solo el 13,3 por ciento necesitó dosis rescate frente al 26,7 por ciento en el multimodal. Las complicaciones más frecuentes fueron hipotensión (23,3 por ciento) y bradicardia (10 por ciento), sin diferencias entre grupos. La analgesia aceleró la recuperación en el 87,5 por ciento de los casos en el grupo peridural superior al 76 por ciento del grupo multimodal. Conclusiones: La analgesia peridural continua con bupivacaína y fentanilo es más eficaz que la analgesia multimodal endovenosa en la cirugía de colon y acelera la recuperación posoperatoria(AU)

Introduction: In colon surgery, accelerated recovery is pursued and the most advantageous analgesic method is still under debate. Objective: To compare the analgesic efficacy of continuous epidural infusion with bupivacaine and fentanyl versus parenteral analgesia in this type of operation. Methods: A quasiexperimental, prospective and longitudinal study was carried out with thirty patients who underwent colon surgery, between August 2018 and August 2019 at Dr. Carlos J. Finlay Central Military Hospital, nonrandomly divided into an epidural analgesia group and a multimodal intravenous analgesia group. Results: The awakening and extubation time in the epidural group was lower (1.6 -1.8 min) than the 4.9 to 5.0 min for the multimodal group. The same happened with intensive care unit and hospital stay, although with a discrete difference. 60 percent of the patients from the epidural group presented hydroaerial noise within the first 24 hours and 80 percent expelled gasses at 48 hours or earlier, with a marked difference in the multimodal group. Analgesia was good in both groups, with lower visual analog scale values in the peridural group; only 13.3 percent required rescue doses compared to 26.7 percent in the multimodal group. The most frequent complications were hypotension (23.3 percent ) and bradycardia (10 percent ), without differences between groups. Analgesia accelerated recovery for 87.5 percent of cases in the epidural group, compared to 76 percent in the multimodal group. Conclusions: Continuous epidural analgesia with bupivacaine and fentanyl is more effective than multimodal intravenous analgesia in colon surgery and accelerates postoperative recovery(AU)

Assessment of The Addition of Epinephrine to Intra-articular Bupivacaine for the Control of Acute Pain in Patients underwent to Anterior Cruciate Ligament Reconstruction / Avaliação da adição da epinefrina à bupivacaína intra-articular no controle da dor aguda em pacientes submetidos a reconstrução do ligamento cruzado anterior

Abstract Objective To evaluate postoperative pain, using the visual analog scale (VAS), in patients undergoing anterior cruciate ligament reconstruction (ACLR) and receiving intra-articular anesthetic solutions. Methods The present is a randomized clinical trial with a sample of 48 patients divided into 4 groups: Group I (n » 12) - 20 mL of saline solution (control); Group II (n » 12) - 20 mL of 0.5% bupivacaine; Group III (n » 12) - 20 mL of 0.5% bupivacaine þ 0.1 mg of epinephrine; and Group IV (n » 12) - 20 mL of saline solution þ 0.1 mg of epinephrine. These solutions were injected into the knee at the end of the surgery. Pain was assessed using the VAS immediately and 6, 12, 24 and 48 hours after the procedure. Results The VAS scores were highly variable among the groups. A Kruskal-Wallis analysis of variance (ANOVA), considering a level of significance of 5%, revealed that all intra-articular anesthetic solutions influenced the assessment of pain (p » 0.003), and that Group-III subjects presented less postoperative pain. There was no evidence of a higher or lower use of supplemental analgesic agents, or of adverse effects resulting from these anesthetic solutions. Conclusion Bupivacaine combined with epinephrine was the most effective solution for pain control in patients undergoing ACLR, but with no statistically significant differences when compared to Group II (p » 0.547). There was no decrease or increase in the use of supplemental analgesics or in the occurrence of adverse systemic effects (p > 0.05).

Resumo Objetivo Avaliar primariamente a dor pós-operatória, por meio da escala visual analógica (EVA), nos pacientes submetidos a reconstrução do ligamento cruzado anterior (RLCA) que receberam soluções anestésicas intra-articulares (IAs). Métodos Ensaio clínico randomizado com uma amostra de 48 pacientes, divididos em 4 grupos: Grupo I (n » 12) - 20 ml de solução fisiológica (controle); Grupo II (n » 12) - 20 ml de bupivacaína a 0,5%; Grupo III (n » 12) - 20 ml de bupivacaína a 0,5% þ 0,1 mg de epinefrina; e Grupo IV (n » 12) - 20 ml de solução fisiológica þ 0,1 mg de epinefrina, injetados no joelho ao término da cirurgia. A dor foi avaliada pela EVA imediatamente e 6, 12, 24 e 48 horas após o procedimento. Resultados Observou-se grande variabilidade nos resultados da EVA entre os pacientes avaliados em cada grupo. Verificou-se, pela análise de variância (analysis of variance, ANOVA) de Kruskal-Wallis, considerando um nível de 5% de significância, que as soluções anestésicas IAs de cada grupo influenciaram na avaliação da dor desses pacientes (p » 0,003), sendo os do Grupo III os que apresentaram menor dor pósoperatória. Não se evidenciou um maior ou menor consumo de drogas analgésicas suplementares, ou efeitos adversos das decorrentes das soluções empregadas. Conclusão A solução combinada de bupivacaína e epinefrina foi a mais eficaz no controle da dor nos pacientes submetidos a RLCA, mas sem diferenças estatisticamente significativas com relação ao grupo II (p » 0,547). Não se observou diminuição ou aumento no consumo de analgésicos suplementares, ou o aparecimento de efeitos sistêmicos adversos (p > 0,05).

Tratamiento farmacológico del estrabismo / Pharmacological treatment of strabismus

La cirugía de la musculatura extraocular ha sido el estándar de atención para tratamiento quirúrgico del estrabismo por más de un siglo. A pesar del gran desarrollo técnico de la cirugía de estrabismo en la actualidad, la utilización de microscopio quirúrgico, el diseño novedoso del instrumental quirúrgico, la calidad de la sutura no reabsorbible; los avances en equipamiento y fármacos anestésicos, la misma no está exenta de complicaciones quirúrgicas, además del tiempo de recuperación que necesita el paciente para reincorporarse a sus actividades sociales, han propiciado una búsqueda permanente del tratamiento farmacológico para el estrabismo. El objetivo de esta revisión bibliográfica es analizar las distintas alternativas farmacológicas disponibles como tratamiento del estrabismo. Para su confección se consultó textos completos y artículos en idiomas español e inglés, disponible en algunas bases de datos. Concluimos que aunque se han estudiado numerosos fármacos, la toxina botulínica que es la más conocida y utilizada mundialmente, seguida de la bupivacaína. Encontramos otros como la IGF I y II (Insuline Growing Factor), capaces de generar un efecto de reforzamiento de la actividad muscular. Y otros que "debilitan" la musculatura extraocular, incluyen la mAb35-Rubicina, BMP4 (Proteína morfogénica ósea). Se continúa su investigación en la actualidad(AU)

Extraocular musculature surgery has been the standard of care for surgical treatment of strabismus for more than a century. Despite the great technical development of strabismus surgery today, the use of a surgical microscope, the novel design of surgical instruments, the quality of the non-absorbable suture; Advances in anesthetic equipment and drugs, it is not exempt from surgical complications, in addition to the recovery time that the patient needs to return to their social activities, have led to a permanent search for pharmacological treatment for strabismus. The objective of this bibliographic review is to analyze the different pharmacological alternatives available as a treatment for strabismus. For its preparation, full texts and articles in Spanish and English languages were consulted, available in some databases. We conclude that although numerous drugs have been studied, botulinum toxin, which is the best known and used worldwide, followed by bupivacaine. We find others such as IGF I and II (Insuline Growing Factor), capable of generating an effect of reinforcing muscle activity. And others that "weaken" MOE include mAb35-Rubicin, BMP4 (Bone Morphogenic Protein). His research is continuing today(AU)

Analgesia posoperatoria en la videolaparascopía de urgencia mediante irrigación de bupivacaína intraperitoneal / Posoperative analgesia in emergency videolaparoscopy through intraperitoneal bupivacaine irrigation

Introducción: La videolaparascopía es un procedimiento frecuente en los servicios de urgencias de cirugía general. El dolor agudo después de estas intervenciones es de naturaleza compleja y requiere un tratamiento analgésico efectivo. Objetivo: Determinar la utilidad del empleo de bupivacaína intraperitoneal en el alivio del dolor posoperatorio en la videolaparascopía de urgencia. Métodos: Se realizó un estudio longitudinal prospectivo y analítico en 80 pacientes mayores de 18 años, anunciados para videolaparoscopía bajo anestesia general orotraqueal en el servicio de urgencias del HMC: Dr. Luis Díaz Soto, desde septiembre de 2016 hasta septiembre de 2018. Los pacientes fueron divididos aleatoriamente en dos grupos de 40 cada uno. Al grupo 1 se aplicó lidocaína transdérmica preincisional en las incisiones de piel y, al término de la cirugía, se irrigaron ambos hemidiafragmas con bupivacaína al 0,25 por ciento. Al grupo 2 se le administró dosis preincisional de analgésicos endovenosos solamente. Resultados: Predominó significativamente el sexo femenino sin diferencia entre grupos. La analgesia posoperatoria fue mejor en el grupo 1 estadísticamente significativa a las 4, 8 y 12 horas. Los requerimientos de analgesia de rescate fueron menores en el grupo 1 (p=0,0024). No se reportaron efectos adversos. Conclusiones: La administración de lidocaína transdérmica preincisional y la instilación de bupivacaína intraperitoneal al final de la videolaparoscopía de urgencia, reduce significativamente el dolor en las primeras horas de posoperatorio. Su aplicación es sencilla, fácil y segura sin evidencias de efectos adversos(AU)

Introduction: Videolaparoscopy is a frequent general surgery procedure in emergency services. Acute pain after these interventions is complex in nature and requires effective analgesic treatment. Objective: To determine the usefulness of intraperitoneal bupivacaine in the relief of postoperative pain in emergency videolaparoscopy. Methods: A prospective, analytical and longitudinal study was carried out in eighty patients older than eighteen years old, announced for videolaparoscopy under orotracheal general anesthesia in the emergency department of Hospital Militar Central Dr. Luis Díaz Soto, from September 2016 to September 2018. The patients were randomly divided into two groups of forty individuals each. Group 1 was applied pre-incisional transdermal lidocaine on skin incisions and, at the end of surgery, both hemidiaphragms were irrigated with bupivacaine 0.25 percent. Group 2 received pre-incisional doses of intravenous analgesics only. Results: The female sex predominated significantly, without difference between the two groups. Postoperative analgesia was better in group 1, insofar it was statistically significant at four, eight and twelve hours. Rescue analgesia requirements were lower in group 1 (p=0.0024). No adverse effects were reported. Conclusions: The administration of pre-incisional transdermal lidocaine and the instillation of intraperitoneal bupivacaine at the end of emergency videolaparoscopy significantly reduces pain during the first hours after surgery. Its application is simple, easy and safe, without evidence of adverse effects(AU)

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.

Safety of local anesthetics

Abstract Local anesthetics are essential medications for the conduction of dermatological procedures. They stop the depolarization of nerve fibers and are divided into two main categories, the amide and ester types. Systemic toxicity with reflex on the central nervous and cardiovascular systems is their most feared adverse reactions, and the anaphylactic reaction is the most concerning one. Although potentially fatal, these events are extremely rare, so local anesthetics are considered safe for use in in-office procedures.

Eficacia del fentanilo en anestesia raquídea para el dolor agudo postoperatorio / Efficacy of fentanil in spinal anesthesia for acute postoperative pain

Objetivo: El dolor agudo postoperatorio es un conjunto de percepciones sensoriales, emocionales y mentales desagradables, asociadas a respuestas autonómicas, psicológicas y conductuales, precipitadas por el acto quirúrgico. Objetivo: Generar conocimiento sobre la eficacia del fentanilo en anestesia raquídea para el dolor agudo postoperatorio. Material y métodos: Es un estudio descriptivo de búsqueda bibliografía y se ha realizado en Pubmed, Medline, Scielo, bibliotecas de universidades nacionales e internacionales. Resultados: La asociación de fentanilo a los anestésicos locales para la anestesia subaracnoidea, reduciendo la dosificación de anestésico local y manteniendo el tiempo de su recuperación y así de esta manera mejorar la calidad, la tasa de éxito de pequeñas dosis de los mismos, con ello, la incidencia de complicaciones hemodinámicas. La administración subaracnoidea de anestésicos locales y opioides, provocan eventos adversos, prurito (30 %), náuseas y vómito (25 %), retención urinaria (10-53 %), depresión respiratoria (3 %). Las diferentes dosis de fentanilo asociado a bupivacaína 0.5%, en la raquianestesia disminuyen la intensidad de dolor según EVA, en el trans-operatorio y el manejo del dolor agudo post-operatorio en los diferentes actos quirúrgicos. Conclusión: Se concluye que la asociación de bupivacaína 0,5% más fentanilo, mediante la técnica raquídea, en pacientes intervenidos quirúrgicamente, resulta eficaz, debido a que permite obtener un menor tiempo de latencia para el bloqueo con una duración prolongada, manteniendo una adecuada hemodinamia y estabilidad respiratoria, y también reduciendo el dolor postoperatorio y sus posibles reacciones adversas. (AU)

Introduction: Acute postoperative pain is a set of unpleasant sensory, emotional and mental perceptions associated with autonomic, psychological and behavioral responses precipitated by the surgical act. Objective: Generate knowledge about the efficacy of fentanyl in spinal anesthesia for acute postoperative pain. Material and methods: It is a descriptive study of literature search and has been carried out in Pubmed, Medline, Scielo, libraries of national and international universities. Results: The association of fentanyl with local anesthetics for subarachnoid anesthesia, reduces the dose of local anesthetic, without prolonging the recovery time, improving the quality, the success rate of small doses of them, with this, the incidence of hemodynamic complications. The subarachnoid administration of local anesthetics and opioids, cause adverse events, itching (30%), nausea and vomiting (25%), urinary retention (10-53%), respiratory depression (3%), all this as a result of interactions with opioid receptors at the brain level. The different doses of fentanyl associated with 0.5% bupivacaine, in spinal anesthesia reduce the intensity of pain according to EVA, in the trans-operative period and the management of acute post-operative pain in the different surgical acts. Conclusion: It is concluded that the association of 0.5% bupivacaine plus fentanyl, through the spinal technique, in surgically treated patients, is effective, since it allows to reach a shorter time of onset of the blockade and longer duration of the block, maintaining adequate hemodynamic and respiratory stability, the time it reduces acute post-operative pain and adverse reactions. (AU)

Anestesia espinal con morfina y bupivacaína en la cirugía de próstata / Spinal anesthesia with morphine and bupivacaine in prostate surgery

Introducción: El dolor posoperatorio constituye la principal causa de dolor agudo en el mundo. Brindar analgesia adecuada en el posquirúrgico garantiza la disminución de la estadía hospitalaria y tiene un impacto positivo en el resultado final de las intervenciones. Objetivo: Evaluar la efectividad de la analgesia posoperatoria con bupivacaína más morfina intratecal en la cirugía de próstata. Métodos: Se realizó una investigación cuasiexperimental, entre enero de 2015 y enero de 2018. La muestra quedó conformada de manera no probabilística por los pacientes que dieron su consentimiento informado y reunieron criterios para entrar en el estudio. Quedaron distribuidos de manera aleatoria en dos grupos denominados bupivacaína (B) y morfina-bupivacaína (MB). Para recolectar la información se emplearon las historias clínicas anestésicas y un formulario elaborado al efecto. Los resultados se mostraron en tablas y gráficos, se expresaron en frecuencias absolutas y en porcientos, se determinaron algunas medidas descriptivas de interés que mostraron el comportamiento de las variables que lo requirieron. Resultados: El resultado más relevante fue el efecto analgésico muy significativo en el grupo MB en las primeras 24 h del posoperatorio. La reacción adversa más frecuente fue el prurito y solo se presentó en el grupo que recibió morfina. Conclusiones: La anestesia espinal con morfina y bupivacaína es efectiva y segura, proporcionando mejor analgesia en el posoperatorio inmediato cuando se compara con bupivacaína sola(AU)

Introduction: Postoperative pain is the main cause of acute pain worldwide. Providing suitable analgesia in the postoperative period guarantees the reduction of hospital stay and has a positive impact on the final outcome of the interventions. Objective: To evaluate the effectiveness of postoperative analgesia with intrathecal administration of bupivacaine plus morphine in prostate surgery. Methods: A quasiexperimental research was carried out between January 2015 and January 2018. The sample was nonprobabilistic and made up by the patients who gave their informed consent and met criteria to enter the study. They were randomly distributed into two groups called bupivacaine (B) and morphine-bupivacaine (MB). To collect the information, the anesthetic medical records and a form prepared for this purpose were used. The results were shown in tables and graphs, expressed in absolute frequencies and percentages, some descriptive measures of interest were determined which showed the behavior of the variables that required it. Results: The most relevant result was the very significant analgesic effect in the MB group in the first 24 hours after surgery. The most frequent adverse reaction was pruritus and only occurred in the group that received morphine. Conclusions: Spinal anesthesia with morphine and bupivacaine is effective and safe, providing better analgesia in the immediate postoperative period when compared with bupivacaine alone(AU)

Analgesia subaracnoidea en el trabajo de parto: bupivacaína/fentanilo vs. petidina / Subarachnoid analgesia in labor: bupivacaine/fentanyl vs pethidine

Introducción: La analgesia subaracnoidea es una alternativa para el trabajo de parto por su seguridad y adecuada relación riesgo/beneficio. Objetivo: Evaluar la efectividad de la analgesia durante el trabajo de parto con la comparación de dos métodos analgésicos. Método: Se realizó un estudio cuasiexperimental, longitudinal y prospectivo en 92 gestantes que se atendieron en el Hospital General Docente Abel Santamaría Cuadrado durante el período entre enero de 2014 y enero de 2017. Las pacientes se dividieron en dos grupos de 46 cada uno, al azar, por orden de llegada a la unidad quirúrgica. El grupo A, bupivacaína al 0,5 por ciento, en dosis de 2 mg y fentanilo en dosis de 25 mcg; y grupo B en el que se utilizó petidina en dosis de 25 mg, en todos los casos por vía intratecal. Las variables analizadas fueron: tensión arterial media, frecuencia cardíaca media, saturación parcial de oxígeno, tiempo de inicio de la analgesia, calidad analgésica, efectos adversos y nivel de satisfacción de las pacientes. Se empleó el análisis descriptivo y la diferencia de proporciones. Resultados: El grupo A mantuvo una TAM entre 84 y 88 mmHg, (Z= 6,0 significativa); FC media entre 80 y 88 lat/min, (Z= 1,94 no significativa); SpO2 con una media de 99,2 por ciento. En 46,74 por ciento (43 casos) el tiempo de inicio de la analgesia fue corto (Z= 8,47), siendo Buena en 100 por ciento de los casos (Z= 6,89 significativa), con recién nacido vigoroso en 100 por ciento (Z= 10,25 significativa). La evolución fue satisfactoria en 48,19 por ciento de las pacientes. Presentaron prurito 8,69 por ciento. En el grupo B hubo hipertensión arterial en 2,17 por ciento de los casos, con menos estabilidad de la FC, tiempos mayores de inicio de trabajo de parto en 12,96 por ciento y fue Buena en 40,22 por ciento. Estas pacientes mostraron menos satisfacción (41,30 por ciento). Conclusiones: La administración subaracnoidea de fentanilo/bupivacaína fue más efectiva que la petidina para la analgesia durante el trabajo de parto(AU)

Introduction: Subarachnoid analgesia is an alternative for labor due to its safety and suitable risk-benefit relationship. Objective: To evaluate the effectiveness of analgesia during labor with the comparison of two analgesic methods. Method: A quasiexperimental, longitudinal and prospective study was carried out in 92 pregnant women who attended Abel Santamaría Cuadrado General Teaching Hospital during the period between January 2014 and January 2017. The patients were divided into two groups of 46 each, randomly assigned, in order of arrival to the surgical unit. Group A was treated with intrathecal administration of bupivacaine 0.5 percent, in a dose of 2 mg, and fentanyl in a dose of 25 mcg; and group B was treated with intrathecal administration of pethidine, in a dose of 25 mg. The variables analyzed were mean arterial blood pressure, mean heart rate, partial oxygen saturation, time of onset of analgesia, analgesic quality, adverse effects and level of patient satisfaction. The descriptive analysis and the difference in proportions were used. Results: Group A maintained a mean arterial blood pressure between 84 and 88 mmHg, (Z=6.0 significant); heart rate averages between 80 and 88 beats per minute, (Z=1.94 not significant); partial oxygen saturation with an average of 99.2 percent. In 46.74 percent (43 cases) the time of onset of analgesia was short (Z=8.47), being good in 100 percent of the cases (Z=6.89 significant), with vigorous newborn in 100 percent (Z=10.25 significant). The evolution was satisfactory in 48.19 percent of the patients. They presented pruritus 8.69 percent. In group B, there was arterial hypertension in 2.17 percent of the cases, with less stability of the heart rate, greater times of labor beginning in 12.96 percent and it was good in 40.22 percent. These patients showed less satisfaction (41.30 percent). Conclusions: Subarachnoid administration of fentanyl/bupivacaine was more effective than pethidine for analgesia during labor(AU)

Efectividad de la anestesia espinal con morfina y bupivacaína en la cirugía de próstata / Effectiveness of spinal anesthesia with morphine and bupivacaine in prostate surgery

Introducción: El dolor posoperatorio constituye la principal causa de dolor agudo en el mundo. Brindar analgesia adecuada en el posquirúrgico garantiza la disminución del tiempo de estancia hospitalaria y tiene un impacto positivo en el resultado final de los pacientes. Objetivo: Evaluar la calidad de la analgesia posoperatoria con bupivacaína más morfina intratecal en la cirugía electiva de próstata, así como la incidencia de efectos adversos. Métodos: Se realizó una investigación cuasiexperimental, entre enero de 2014 y julio de 2017. La muestra quedó conformada de manera no probabilística por los pacientes que dieron su consentimiento informado y reunieron criterios para entrar en el estudio. Quedaron distribuidos de manera aleatoria en dos grupos denominados bupivacaína (B) y morfina-bupivacaína (MB). Para recolectar la información se emplearon las historias clínicas anestésicas y un formulario elaborado al efecto. Los datos se mostraron en tablas y gráficos, los resultados se expresaron numéricamente y en porcientos, se determinaron algunas medidas descriptivas de interés que mostraron el comportamiento de las variables que lo requirieron. Resultados: El resultado más relevante fue el efecto analgésico muy significativo en el grupo MB en las primeras 24 h del posoperatorio. La reacción adversa más frecuente fue el prurito y solo se presentó en el grupo que recibió morfina. Conclusiones: La anestesia espinal con morfina y bupivacaína es efectiva y segura, proporcionando mejor analgesia en el posoperatorio inmediato cuando se compara con bupivacaína sola(AU)

Introduction: Postoperative pain is the main cause of acute pain worldwide. Providing adequate analgesia postoperatively guarantees hospital stay reduction and positively affects patient outcome. Objective: To evaluate the quality of postoperative analgesia with bupivacaine plus intrathecal morphine in elective prostate surgery, as well as the incidence of adverse effects. Methods: A quasiexperimental research was carried out between January 2014 and July 2017. The sample was chosen in a non-probabilistic way and made up by the patients who gave their informed consent and met the inclusion criteria to enter the study. They were randomly distributed into two groups identified as bupivacaine (B) and morphine-bupivacaine (MB). To collect the information, the anesthetic medical records were used, together with a form prepared for such purpose. The data were shown in charts and graphs, the results were expressed numerically and in percentages, some descriptive measures of interest were determined that showed the behavior of the variables that required it. Results: The most relevant outcome was the very significant analgesic effect in the MB group in the first 24 hours after surgery. The most common adverse reaction was pruritus and only occurred in the group that received morphine. Conclusions: Spinal anesthesia with morphine and bupivacaine is effective and safe because it provides better analgesia in the immediate postoperative period in comparison to bupivacaine alone(AU)

Anestesia epidural y control posoperatorio de la tensión arterial en pacientes con preeclampsia grave cesareadas / Epidural anesthesia and postoperative control of arterial pressure in patients with serious preeclampsia and who have undergone cesarean section

Introducción: La preeclampsia en Cuba tiene una incidencia de 10 a 12 y una mortalidad neonatal de 35 por ciento. Hay escasa evidencia acerca de si es adecuado el tratamiento estándar. Se acepta el uso de anestesia epidural en la preeclampsia grave porque, entre otros beneficios, estabiliza la presión arterial. Objetivo: Evaluar la eficacia de la anestesia epidural continua como coadyuvante en el control posoperatorio de la tensión arterial en pacientes con preeclampsia grave. Métodos: Se realizó un estudio experimental en el hospital Dr. Agostinho Neto en el periodo 2013-2016. Se incluyeron 180 gestantes entre 15 y 40 años con preeclampsia grave intervenidas por cesárea, ASA III; asignadas aleatoriamente a un grupo de estudio y otro de control. En ambos se procedió según la norma cubana de obstetricia para el tratamiento de la preeclampsia. El grupo control recibió analgesia posoperatoria según recomendaciones del protocolo hospitalario, mientras se empleó anestesia epidural continua con 12,5 mg/h de bupivacaína al 0,125 por ciento en el grupo de estudio. Se midió la tensión arterial sistólica, diastólica y media durante las ocho primeras horas posoperatorias: Resultados: La tensión arterial sistólica y diastólica se controló en 93 por ciento y 88 por ciento, respectivamente. En el grupo control, 47 por ciento necesitó tres drogas antihipertensivas, 6 por ciento evolucionó hacia la eclampsia. Se controlaron los síntomas en el 97 por ciento del grupo de estudio. La taquicardia fue el efecto secundario esperado más frecuente de la anestesia epidural. Conclusiones: La anestesia epidural con bupivacaína al 12,5 mg/h es eficaz como coadyuvante en el control de la tensión arterial en el posoperatorio de pacientes con preeclampsia grave(AU)

Introduction: Preeclampsia in Cuba has an incidence of 10 to 12 and a neonatal mortality of 35 percent. There is little evidence about the standard treatment. The use of epidural anesthesia in severe preeclampsia is accepted because, among other benefits, it stabilizes blood pressure. Objective: To evaluate the effectiveness of continuous epidural anesthesia as an adjuvant in the postoperative control of blood pressure in patients with severe preeclampsia. Method: An experimental study was performed at Dr. Agostinho Neto Hospital in the period 2013-2016. We included 180 pregnant women aged 15-40 and with severe preeclampsia undergoing cesarean section (ASA III), randomly assigned to a study group and a control group. In both cases, we used the Cuban obstetrical standard for treating preeclampsia. The control group received postoperative analgesia according to the recommendations of the hospital protocol, while continuous epidural anesthesia was used with 12.5 mg/h of bupivacaine 0.125 percent in the study group. Systolic, diastolic and mean arterial pressure were measured during the first eight postoperative hours. Results: Systolic and diastolic blood pressure was controlled in 93 percent and 88 percent, respectively. In the control group, 47 percent needed three antihypertensive drugs, while 6 percent evolved towards eclampsia. Symptoms were controlled in 97 percent of the study group. Tachycardia was the most common expected side effect of epidural anesthesia. Conclusions: Epidural anesthesia with 12.5 mg/h of bupivacaine is effective as an adjuvant in controlling postoperative blood pressure in patients with severe preeclampsia(AU)

Anestesia subaracnoidea con dosis variables de bupivacaina con fentanilo, en la resección transuretral de la próstata / Subarachnoid anesthesia with variable doses of bupivacaine with fentanyl in the trans-urethral resection of the prostate

Introducción: en la actualidad se han descrito diversos modelos de raquianestesia con bupivacaína a dosis diferentes, asociadas o no con fentanilo, que proveen de una anestesia segura y eficaz, disminuyen la intensidad de dolor posquirúrgico, preservan la función cognoscitiva, y reduce las complicaciones atribuidas a la lidocaína hiperbárica por neurotoxicidad. Objetivo: evaluar el efecto de bajas dosis de bupivacaína con fentanilo para anestesia subaracnoidea en pacientes sometidos a resección transuretral de próstata. Materiales y Métodos: se realizó un estudio descriptivo cuantitativo, longitudinal, prospectivo en 200 pacientes programados para dicha cirugía e indicación de anestesia subaracnoidea con bupivacaína, los cuales fueron distribuidos de forma aleatoria en cuatro grupo. Resultados: tanto el bloqueo sensitivo como motor fue más rápido en los pacientes de los Grupos B (3,0; 11,2) y (7,1; 8,3), Grupo C (5,0; 9,4) y (6,2; 9,4) y Grupo D (6,1; 8,3) y (4,7; 10,9); mientras que el Grupo A fue de (6,0; 8,5) y (9,9; 11,7), respectivamente. Se observó que en la totalidad de los pacientes de los Grupos C y D se obtuvo anestesia de buena calidad. Conclusiones: la administración intratecal de 7,5 mg de bupivacaina con 25 µg de fentanilo produjo anestesia satisfactoria, disminuyó el periodo de latencia, mantuvo mejor estabilidad hemodinámica, prolongó la analgesia postoperatoria y se asoció a menor incidencia de complicaciones peri operatorias (AU).

Introduction: currently, several models of spinal anesthesia with bupivacaine in different doses, associated or not to fentanyl, have been described providing a safe and efficacious anesthesia, reducing the intensity of the postsurgical pain, preserving the cognitive function, and reducing the complications attributed to hyperbaric lidocaine due to its neurotoxicity. Aim: to assess the effect of low doses of bupivacaine with fentanyl as subarachnoid anesthesia in patients undergoing a prostate trans-urethral resection. Materials and Methods: a prospective, longitudinal, quantitative, descriptive study was carried out in 200 patients programmed for that kind of surgery and with the indication of subarachnoid anesthesia through bupivacaine; they were randomly distributed in four groups. Outcomes: both, the sensory block and the motor one were faster in the patients of the Group B (3,0; 11,2) and (7,1; 8,3), Group C (5,0; 9,4) and (6,2; 9,4) and Group D (6,1; 8,3) and (4,7; 10,9); while in the patients of the Group A they were (6,0; 8,5) y (9,9; 11,7) respectively. It was observed a good quality anesthesia in all the patients of the Groups C and D. Conclusions: the intrathecal administration of 7,5 mg of bupivacaine with 25 µg of fentanyl produced a satisfactory anesthesia, reduced the latency period, kept a better hemodynamic stability up, extended the post-surgery analgesia and was associated to fewer incidences of perioperative complications (AU).

Spinal injection of local anesthetic during cervical facet joint injection / Injeção espinhal de anestésico local durante injeção em facetas articulares cervicais

Abstract Introduction: Facet joint pain is a common source of non-radicular back pain worldwide. Non-surgical interventional modalities remain the mainstay in the treatment of facetogenic back pain and comprise the second most commonly performed interventional pain procedures in the USA. Case: A 36 year-old man with chronic cervical pain secondary to C6-C7 facet arthrosis radiographically, underwent diagnostic local anesthetic bilateral facet joint injection under fluoroscopic guidance. The left side was injected uneventfully; however, 1-2 min following injection of the right side the patient complained of unwellness and became very anxious. He referred paresthesias of the bilateral upper extremities, chest and upper abdomen. Physical examination showed sensory deficits roughly from C5 to T7 without motor deficits; resuscitation measures were not warranted. The deficits were completely resolved by 35-40 min in the recovery area. Discussion: Facet joint injections are a common and safe method of treating back pain secondary to facet arthropathy. Despite excellent safety profiles, rare and sometimes, life-threatening complications can occur. Our case hypothesizes intrathecal injection of local anesthetic during facet joint injection. Few reports have described similar situations. We hypothesize a mechanism of entry through the facet joint, given the proximity of the ligamentum flavum, and the intrathecal space to the anterior aspect of the facet joint. This report reinforces the need for resuscitation and airway management equipment to be readily available where interventional procedures are performed, as well as the need for adequate proficiency in airway management and resuscitation techniques in Pain Medicine training.

Resumo Introdução: A dor nas articulações facetárias é uma fonte mundialmente comum de dores nas costas não radiculares. As modalidades de intervenções não cirúrgicas continuam sendo os pilares no tratamento da dorsalgia facetária e ocupam o segundo lugar entre os procedimentos mais comumente feitos nos EUA para o manejo da dor. Relato de caso: Paciente do sexo masculino, 36 anos, com dor cervical crônica secundária à artrose facetária em C6-C7 (confirmada por radiografia), submetido a exame diagnóstico bilateral das facetas com injeção de anestésico local sob orientação fluoroscópica. O lado esquerdo foi injetado sem intercorrências; porém, um-dois minutos após a injeção do lado direito, o paciente queixou-se de mal-estar e ficou muito ansioso. Mencionou parestesia nos braços, no tórax e no abdome superior. O exame físico revelou déficits sensoriais de, aproximadamente, C5 a T7, sem déficit motor; medidas de reanimação não eram justificáveis. Os déficits foram completamente resolvidos em 35-40 minutos na área de recuperação. Discussão: A aplicação de injeções nas articulações facetárias é um método comum e seguro de tratar a dor nas costas secundária à artropatia facetária. Apesar dos excelentes perfis de segurança, complicações raras e, às vezes, com risco de morte podem ocorrer. Nosso caso relata a injeção intratecal de anestésico local durante injeção nas facetas articulares. Poucos relatos descreveram situações semelhantes. Levantamos a hipótese de um mecanismo de entrada através da faceta articular, por causa da proximidade do ligamento amarelo e do espaço intratecal com o aspecto anterior da faceta articular. Esse relato reforça a necessidade de reanimação e de equipamentos para o manejo das vias aéreas estarem prontamente disponíveis quando procedimentos intervencionistas são feitos, bem como a necessidade de estabelecer o domínio do conhecimento no manejo das vias aéreas e das técnicas de reanimação e treinamento em medicina da dor.

Bilateral greater occipital nerve block for treatment of post-dural puncture headache after caesarean operations / Bloqueio bilateral do nervo occipital maior para tratamento de cefaleia pós-punção dural após cesarianas

Abstract Background: Post-dural puncture headache (PDPH) is an important complication of neuroaxial anesthesia and more frequently noted in pregnant women. The pain is described as severe, disturbing and its location is usually fronto-occipital. The conservative treatment of PDPH consists of bed rest, fluid theraphy, analgesics and caffeine. Epidural blood patch is gold standard theraphy but it is an invasive method. The greater occipital nerve (GON) is formed of sensory fibers that originate in the C2 and C3 segments of the spinal cord and it is the main sensory nerve of the occipital region. GON blockage has been used for the treatment of many kinds of headache. The aim of this retrospective study is to present the results of PDPH treated with GON block over 1 year period in our institute. Methods: 16 patients who had been diagnosed to have PDPH, and performed GON block after caesarean operations were included in the study. GON blocks were performed as the first treatment directly after diagnose of the PDPH with levobupivacaine and dexamethasone. Results: The mean VAS score of the patients was 8.75 (±0.93) before the block; 3.87 (±1.78) 10 min after the block; 1.18 (±2.04) 2 h after the block and 2.13 (±1.64) 24 h after the block. No adverse effects were observed. Conclusions: Treatment of PDPH with GON block seems to be a minimal invasive, easy and effective method especially after caesarean operations. A GON block may be considered before the application of a blood patch.

Resumo Justificativa: A cefaleia pós-punção dural (CPPD) é uma complicação importante da anestesia neuroaxial e mais frequentemente observada em grávidas. A dor é descrita como intensa, perturbadora, e sua localização é geralmente fronto-occipital. O tratamento conservador da CPPD consiste em repouso no leito, fluidoterapia, analgésicos e cafeína. O tampão sanguíneo peridural é o padrão ouro de tratamento, mas é um método invasivo. O nervo occipital maior (NOM) é formado por fibras sensoriais com origem nos segmentos C2 e C3 da medula espinhal e é o principal nervo sensorial da região occipital. O bloqueio do NOM tem sido usado para o tratamento de muitos tipos de dor de cabeça. O objetivo deste estudo retrospectivo foi apresentar os resultados de CPPD tratada com bloqueio do NOM no período de um ano em nosso instituto. Métodos: Foram incluídas no estudo 16 pacientes diagnosticadas com CPPD e submetidas a bloqueio de NOM após cesariana. Os bloqueios do NOM foram feitos com levobupivacaína e dexametasona como o primeiro tratamento imediatamente após o diagnóstico de CPPD. Resultados: A média dos escores EVA das pacientes foi de 8,75 (±0,93) antes do bloqueio; 3,87 (±1,78) 10 minutos após o bloqueio; 1,18 (±2,04) duas horas após o bloqueio e 2,13 (±1,64) 24 horas após o bloqueio. Efeitos adversos não foram observados. Conclusões: O tratamento da CPPD com bloqueio do NOM parece ser um método minimamente invasivo, fácil e eficaz, especialmente após cesarianas. O bloqueio do NOM pode ser considerado antes da aplicação de um tampão sanguíneo peridural.

Comparison of different postoperative paın managements in patients submitted to transperitoneal laparoscopic renal and adrenal surgery

ABSTRACTPurpose:We compared the effects of local levobupivacaine infiltration, intravenous paracetamol, intravenous lornoxicam treatments on postoperative analgesia in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.Materials and Methods:Sixty adult patients 26 and 70 years who underwent laparoscopic renal and adrenal surgery were randomized into three groups with 20 patients each: Group 1 received local 20mL of levobupivacaine 0.25% infiltration to the trocar incisions before skin closure. In group 2, 1g paracetamol was given to the patients intravenously 30 minutes before extubation and 5g paracetamol was given intravenoulsy in the 24 postoperative period. In group 3, 8mg lornoxicam i.v. was given 30 minutes before extubation and 8mg lornoxicam i.v. was given in the 24 postoperative period. In the postoperative period, pain scores, cumulative tramadol, and additional pethidine consumption were evaluated.Results:Postoperative pain scores significantly reduced in each group (p < 0.05). Although pain levels of the groups were not significantly different at 1, 2, 4, 8, 12 and 24 hours postoperatively, cumulative tramadol consumptions were higher in group 1 than the others. (Group 1 = 370.6 ± 121.6mg, Group 2: 220.9 ± 92.5mg, Group 3 = 240.7 ± 100.4mg.) (p < 0.005). The average dose of pethidine administered was significantly lower in groups 2 and 3 compared with group 1 (Group 1: 145mg, Group 2: 100mg, Group 3: 100mg) (p = 0.024).Conclusions:Levobupivacaine treated group required significantly more intravenous tramadol when compared with paracetamol and lornoxicam groups in patients submitted to transperitoneal laparoscopic renal and adrenal surgery.

Influence of the peritoneal lavage with bupivacaine on the survival and resistance of colonic anastomoses performed under fecal peritonitis in rats

PURPOSE: To evaluate the effects of peritoneal lavage with bupivacaine on survival and initial resistance of anastomosis on distal colon, performed under peritonitis or not. METHODS: Forty rats, weighing from 300 to 350g (321.29±11.31g), were randomly divided in four groups and underwent laparotomy and anastomosis on the distal colon six hours after induction of peritonitis by intraperitoneal injection of autologous fecal material or not. Group 1: No peritonitis and lavage with 3ml NS; Group 2: No peritonitis and lavage with 8 mg.kg-1 (± 0.5 mL) of 0.5% bupivacaine added to 2.5 mL of NS; Group 3: Peritonitis and lavage with 3ml NS; Group 4: Peritonitis and lavage with 8 mg.kg-1 (± 0.5 mL) of 0.5% bupivacaine added to 2.5 mL of NS. Necropsies were performed on the animals that died and the time of death was recorded. Surviving animals were submitted to euthanasia on the fifth post-operative day and Total Energy of Rupture biomechanical test (TER) was applied. RESULTS: Group 4 showed survival increase compared to Group 3, without statistical significance. Group 3 presented the smallest average TER, with statistical significance. CONCLUSION: Peritonitis increased mortality and influenced negatively the resistance of colic anastomosis in rats. Peritoneal lavage with bupivacaine increased anastomotic resistance.

Eficacia de la analgesia epidural continua con bupivacaína al 0.125 por cento y fentanilo 2 ug/ml en pacientes postoracotomizados. Hospital IV Guillermo Almenara Irigoyen, 2011 / Efficacy of continuous epidural analgesia with 0.12 por cento bupivacaine and 2 ug/ml fentanyl after thoracic surgery. Hospital IV Guillermo Almenara Irigoyen, 2011

Objetivo: Determinar la eficacia analgésica que brinda la administración epidural continua de bupivacaína al 0.125% y fentanilo2 μg/ml en pacientes postoracotomizados. Material y métodos : Se realizó un estudio observacional, prospectivo y descriptivo. La población estuvo conformada por todos los pacientes postoracotomizados durante los meses de marzo y abril del 2012 en elHospital IV Guillermo Almenara Irigoyen. Se evaluó el dolor con la escala visual análoga (EVA) y la escala de Andersen en la unidad de recuperación postanestésica (URPA) y durante las primeras 24 horas en su servicio. De igual manera, se hizo el registro de los eventos colaterales. Se aplicó el ANOVA de medidas repetidas, test de correlación de Pearson y t de student para las medidas dela EVA, y la prueba de chi cuadrado para las medidas de la escala de Andersen. Resultados : La muestra estuvo conformada por veinte pacientes. La edad promedio fue 38 ± 18 años y la lobectomía pulmonar el procedimiento quirúrgico más frecuente (55%). Al ingreso a la URPA la EVA fue 0, luego 1 por 12 horas, 2 a las 24 horas y finalmente 4 a las 48 horas. El dolor leve y moderado,medido por la escala de Andersen, se presentó durante las dos primeras horas. El tiempo que duró la analgesia fue 15.4 ± 7.1 horas. El número de bolos adicionales fue 3 ± 2. El 65% de los pacientes no requirieron analgesia de rescate. La eficacia analgésicamedida por EVA ≤ a 3 fue 85% y medida por Andersen ≤ a 2 fue 80%. 15% presentaron mareo y vómito y 15% sólo náusea. Conclusión:La analgesia epidural continua con bupivacaína al 0.125% y fentanilo 2 μg/ml en pacientes postoracotomizados eseficaz según la evaluación de la EVA y la escala de Andersen

Objective: To determine the analgesic efficacy that continuous epidural administration of 0.125% bupivacaine and 2 æg/ml fentanyl provides in patients after thoracic surgery. Material and Methods: An observational, prospective and descriptive study. The population included all patients who underwent thoracic surgery in March and April 2012 at the Hospital IV Guillermo Almenara Irigoyen. Pain was assessed with visual analogue scale (VAS) and the Andersen scale in the post-anesthesia care unit (PACU) and the next 24 hours. Side events were recorded too. We applied ANOVA for repeated measures, Pearson correlation test and student’s t for measures of VAS, and the chi-square test for measures of Andersen scale. Results: The sample consisted of twenty patients. The mean age was 38 ñ 18 and the most frequent surgical procedure was lung lobectomy (55%). On admission to the PACU VAS was 0, then 1 for 12 hours, 2 at 24 hours and finally 4 at 48 hours. Mild to moderate pain, as measured by the Andersen scale, was present during the first two hours. The analgesia lasted 15.4 ñ 7.1 hours. The number of additional boluses was 3 ñ 2. The 65% of patients did not require rescue analgesia. The analgesic efficacy as measured by EVA less than or equal to 3 was 85% and measured by Andersen scale less than or equal to 2 was 80%. 15% of patients had dizziness and vomiting and 15% only nausea. Conclusion: Continuous epidural analgesia with bupivacaine 0.125% and 2 ug/ml fentanyl in patients after thoracic surgery is effective as assessed by the VAS and Andersen scale.

Uso de bupivacaína hiperbárica versus bupivacaína hipobárica en anestesia espinal unilateral en pacientes ambulatorios sometidos a cirugía electiva por hernia inguinal unilateral: un ensayo clínico controlado aleatorizado de eficacia y seguridad en pacientes atendidos en los hospitales escuela Roberto Calderón Gutiérrez y Antonio Lenin Fonseca, de Junio a Diciembre del 2012 / Use of hyperbaric bupivacaine versus hypobaric bupivacaine in anesthesia unilateral spinal cord in outpatients undergoing elective surgery for Unilateral inguinal hernia: a randomized controlled clinical trial of efficacy and safety in patients treated at Roberto's teaching hospitals Calderón Gutiérrez and Antonio Lenin Fonseca, from June to December 2012

Con el objetivo de comparar la eficacia y seguridad del uso de bupivacaína hiperbárica versus bupivacaínahipobárica en anestesia espinal unilateral en pacientes ambulatorios sometidos a cirugía electiva por hernia inguinal unilateral se llevó a cabo un ensayo clínico controlado aleatorizado en 73 pacientes atendidos en los hospitales escuela Roberto Calderón Gutiérrez y Antonio Lenin Fonseca, de Junio a Diciembre del 2012. Entre los hallazgos más importante se encontró que el nivel de bloqueo motor alcanzado en las dos técnicas anestésicas fueron similares permitió realizar la hernioplastias inguinal con adecuada relajación muscular del lado a ser intervenido. Logrando un nivel metamérico sensitivo óptimo para la cirugía en el 97% de los casos de grupo de estudio y control, esto sugiere que las técnicas son efectivas por lo tanto podemos resaltar que ambas técnicas son similares ya que no presentan diferencias importantes en la proporción de pacientes que alcanzaron un nivel adecuado. Con respecto a la calidad de bloqueo en las dos técnicas empleadas encontramos una mejor analgesia en el grupo de estudio en comparación al grupo control con una diferencia del 19% lo que sugiere que no son clínicamente similares. Se logró establecer que las dos técnicas anestésicas comparten estabilidad hemodinámica ya que no presentan cambios significativos entre ellas con mínimas complicaciones lo que sugiere que la técnica es segura. La técnica anestésica de bloqueo, espinal hipobárico e hiperbárico unilateral para procedimientos de pacientes quirúrgicos ambulatorios es muy útil ya que se logra una pronta recuperación anestésica en los dos grupos de estudio .Se recomienda el uso del bloqueo espinal unilateral hipobárico e hiperbárico para pacientes sometidos a procedimos quirúrgicos ambulatorios como una adecuada alternativa y con fines docentes. El uso de bupivacaína hiperbárica e hipobárica en el bloqueo espinal unilateral son dos técnicas seguras que proporcionan mejor calidad analgésica, estabilidad hemodinámica, pronta recuperación post operatoria con pocas complicaciones por lo tanto se recomienda como una opción más en la práctica diaria del anestesiólogo

Postoperative epidural analgesia: trials of bupivacaine combined with fentanyl or morphine after spinal fusion surgery

Background: major spinal fusion surgery causes severe postoperative pain, which persists for at least 3 days. Efficient and safe methods for postoperative analgesia after spinal fusion surgery are, therefore, mandatory. This study aimed to compare the analgesic effect of different epidural analgesia combinations and their effects on blood level of Beta-endorphin. We also studied the impact of these analgesic regimens on defined postoperative mobilization maneuvers and on patient satisfaction

Methods: This study was registered in clinical trials number NCT01838707. Sixty patients scheduled for elective posterior lumbar fusion surgery for correction of Spondylolisthesis were enrolled in this study. Patients were randomly allocated into three equal groups [20 each] according to analgesic drugs combinations administered through epidural catheter inserted intraoperatively. All patients received standard general anesthesia. Al the end of posterior instrumentation, the surgeon inserted the epidural catheter under direct vision in the midline. All patients in this study were nursed in a high dependency intensive care facility and received analgesics according to the following protocol. Continuous drug flow will be maintained with a syringe pump. The syringe pump was connected to the epidural catheter [with the reservoir contain either: 0.125% Bupivacaine HCI at flow rate of 4 5 ml/h [5-6.25mg/h bupivacaine]. 0.125% Bupivacaine HCI fentanyl 100 microg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine I 6-10 microg /h fentanyl] 0.125% Bupivacaine HCI morphine sulphate 3 mg at flow rate of 3 5 ml/h [3.75-6.24 mg/h bupivacaine 0.18-0.3 mg/h morphine]. Infusion was continued until the third postoperative day. The rate was increased if pain VAS >3 [visual analogue scale] at rest or VAS >6 with movement. The rate was decreased when patients have intolerable relevant motor block [Bromage score >0] or sensory disturbances [numbness], or hypotension [systolic blood pressure <90 mm Hg]. IV rescue analgesia will be Ketrolactromethamine 30 mg. Epidural catheters were removed on the third postoperative day. Pain was assessed using the VAS ranging from "0" [no pain] to "10" [worst imaginable pain]. Pain was evaluated at rest and during mobilization. Maneuvers of particular clinical importance for postoperative mobilization [alone and with help] were chosen: Turning in bed. Standing in front of the bed and walking, and using the toilet without help. The time needed until the patient can first successfully perform these maneuvers was documented. Three venous samples to measure serum B-endorphin level first one preoperative base line, second at first time VAS more three at rest and third sample when VAS less than three at rest. For assessment of patients satisfaction with postoperative pain management a verbal rating score was used. Motor block was quantified with the Bromage scale. Patients will be asked about sensory deficits. Verbal rating scores was used for sedation. Nausea and vomiting and the incidence of pruritus were recorded

Results: There were no significant differences observed between the studied groups regarding patient characteristics [age, sex, ASA status, anesthesia time, surgery duration and number of segments fused]. There were no significant differences in all hemodynamic variables between the three groups, the results of this study showed less pain scores as recorded by VAS all over the study time for group 3 [bupivacaine+ morphine]. Pain scores were lowest for group Ill [bupivacaine + morphine] all over the study time when testing pain during movement. The mean times to turn in bed with and without assistance were lowest in group Ill [bupivacaine morphine]. B-endorphin level, there was no significant differences between means of B-endorphin samples between the groups or within each group. Patients were more satisfied in group 3 all over the study period. The incidence of nausea, vomiting or itching within the observation period was significantly different between the three groups. It was more common in the bupivacaine morphine group

In Conclusion: Epidural analgesia after spine surgery improve pain control and enhance functional recovery, but potential cost issues related to maintenance of the epidural infusion and ICU slay versus potential cost savings in hospital stay and effect on long term outcome must be considered. Also the cost of use B-endorphin as a biomarker of pain severity needs to be revised against the subjective assessment of pain

Spinal lidocaine vs bupivacaine for short duration operative gynecological laparoscopy

Background: The concept that general anesthesia is the only suitable technique for laparoscopic procedures has been changed. Regional anesthesia, including epidural and spinal techniques, combined with the head down position can he used for gynecological laparoscopy without major impairment of ventilation

Aim of the work: This study was designed to compare between lidocaine-fentanyl and bupivacaine-fentanyl spinal anesthesia for operative gynecological laparoscopy regarding the efficacy of the two spinal techniques, patients and surgeons comfort, intra- and postoperative characteristics and complications

Patients and Methods: This is a double blinded randomized prospective study which was conducted at Assuit University Hospital after approval from local ethics committee and informed consent from all patients. The study included 60 women who were scheduled for gynecologic laparoscopy, ASA physical status I and II. Patients were randomly assigned to one of two groups: group I, patients received 2.5 ml 2% plain lidocaine [50 mg] made up to 3 ml solution by addition of 0.5 ml fentanyl [25 microg]. In group II: patients received 2.5 ml 0.5% plain bupivacaine [12.5 mg] made up to 3 ml solution by addition of 0.5 ml fentanyl [25microg]. All patients received 30 mg ketorolac in 500 ml of normal saline, preoperatively, routine monitors were applied [ECG, non invasive blood pressure, pulse oximeter]. The subarachnoid block was performed using a standardized technique. A standardized surgical technique was used for laparoscopy. Shoulder tip pain was recorded and the intensity of pain was measured on a 10-cm visual analog scale [VAS]. Pain >/= 3 on VAS was treated with fentanyl [50microg] and midazolam [1.5 mg] intravenously. Surgical condition, hemodynamic data [non invasive blood pressure [NIBP], heart rate [HR], respiratory rate [RR], O[2] saturation [SpO[2]], arterial blood gas [ABG], intra-operative, and post operative side effects were recorded as nausea, pain and transient neurological symptoms [TNS] in addition to recovery profile including time to full motor and sensory recovery, time to ambulate and time to discharge

Results: There were no significant differences between both groups as regard age, weight, height, body mass index, CO[2] volume and pressure, and pneumoperitonium time. There were no significant differences between the two groups as regard to NIBP, HR, RR, SpO[2], ABG and intra operative complications. Arterial CO[2] tension showed significant increase at 10 min after insufflations in both groups. Surgical condition was rated by surgeons as good to excellent in most patients in both groups with no significant difference between both groups. In the lidocaine group, two patients were excluded from data collection and analysis due to intractable shoulder pain and they required general anesthesia, otherwise shoulder pain >/= 3 on VAS was easily managed in patients in both groups with fentanyl 50microg and midazolam 1.5 mg intravenously. The time to onset of motor block and the time to reach sensory level to T12 and T6 were significantly shorter in the lidocaine group patients in comparison to the bupivacaine group patients. Patients in the lidocaine group showed significantly faster recovery than patients in the bupivacaine group, but unfortunately, they showed significantly higher incidence in TNS than patients in the bupivacaine group. There were no significant differences between both groups regarding postoperative complications

Conclusion: Spinal anesthesia could be a suitable and safe technique for gynecological laparoscopy with a reasonable acceptance from both patients and surgeons. Additionally it possesses the advantage of pain free recovery and low incidence of post operative complications. Even though spinal lidocaine provided faster recovery profile after gynecological laparoscopy than spinal bupivacaine, but it has the disadvantage of higher incidence of TNS