Effect of transcutaneous acupoint electrical stimulation at Neiguan (PC 6) on general anesthesia under preserving spontaneous breathing in thoracoscopic lobectomy / 中国针灸

OBJECTIVE@#To evaluate the effect of transcutaneous acupoint electrical stimulation (TEAS) at Neiguan (PC 6) on general anesthesia under preserving spontaneous breathing in thoracoscopic lobectomy.@*METHODS@#A total of 66 patients of primary lung cancer undergoing thoracoscopic lobectomy were divided to an observation group (33 cases, 1 case discontinued) and a control group (33 cases). In the observation group, TEAS at Neiguan (PC 6) was used 30 min before anesthesia induction till the end of surgery. The surgery time, maximum value of partial pressure of end-tidal carbon dioxide (PETCO2) and minimum value of oxygen saturation (SpO2) of the two groups were recorded. The dosage of propofol, sufentanil, remifentanil and dexmedetomidine were analyzed. Separately, before induction (T0), at the start of surgery (T1), thoracic exploration (T2) and lobectomy (T3), as well as 30 min (T4) and 60 min (T5) after lobectomy, the mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), serum cortisol (Cor) and norepinephrine (NE) were measured. The time of post anesthesia care unit (PACU) stay, ambulation, flatus, chest drainage and the incidence of nausea and vomiting were compared between the two groups.@*RESULTS@#The maximum value of PETCO2, the dosage of propofol and remifentanil in the observation group were lower than those in the control group (P < 0.05, P < 0.01), the minimum value of SpO2 in the observation group was higher than that of the control group (P < 0.01). At T1-T5, the MAP, HR, serum Cor and NE levels in the observation group were all lower than those in the control group (P < 0.05). The ambulation time, the time for the flatus, chest drainage time, and the incidence of nausea and vomiting in the observation group were all lower than those in the control group (P<0.001, P < 0.01).@*CONCLUSION@#For the general anesthesia under preserving spontaneous breathing in thoracoscopic surgery, TEAS at Neiguan (PC 6) relieves stress response, reduces opioids dosage and promotes postoperative recovery.

Continuous flow Aza-Michael reaction for preparing the fast-acting synthetic opioid drug Remifentanil

Abstract Remifentanil is a modern fentanyl analogue with ultrashort-action granted by an esterase-labile methyl propanoate chain. Here, we present the development of a continuous flow methodology for the key N-alkylation step of remifentanil preparation in a biphasic, "slug-flow" regime. We screened parameters under microwave-assisted reactions, translated conditions to flow settings, and obtained remifentanil under 15-min residence time in a 1-mL microreactor, with a space-time yield of 89 mg/mL·h and 94% yield.

Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes

Abstract Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

Effect of dexamethasone combined with oxybuprocaine hydrochloride gel on prevention of postoperative sore throat after nasal endoscopy / 北京大学学报(医学版)

OBJECTIVE@#To explore the effectiveness and feasibility of dexamethasone combined with oxybuprocaine hydrochloride gel on the prevention of postoperative sore throat after nasal endoscopy.@*METHODS@#In the study, 60 patients with American Society of Anesthesiologist (ASA) physical statuses Ⅰ to Ⅱ, aged 18 to 72 years, scheduled for elective nasal endoscope surgery under general anesthesia requiring endotracheal intubation were randomly divided into dexamethasone combined with oxybuprocaine hydrochloride gel group (G group, n=30) and control group (C group, n=30). The patients in the G group received dexamethasone 0.1 mg/kg before induction and the oxybuprocaine gel was applied to the endotracheal catheter cuff and the front end within 15 cm. The patients in the C group received the same dose of saline and the saline was applied to the endotracheal catheter cuff and the front end within 15 cm. Then, all the patients in the two groups received the same induction and anesthesia maintainance. The operation time, anesthesia time, emergence time, extubation time and departure time were recorded. The intraoperative infusion volume, blood loss volume, propofol, remifentanil, rocuronium dosage were also recorded. The adverse reactions such as intraoperative hypotension, bradycardia and postoperative agitation were recorded. The postoperative sore throat score was recorded at the end of operation and 4 h, 8 h, 12 h, and 24 h after operation.@*RESULTS@#Compared with the C group, the emergence time [(8.4±3.9) min vs. (10.8±4.7) min], extubation time [(8.8±3.7) min vs. (11.9±4.8) min], and departure time [(20.0±5.3) min vs. (23.0±5.8) min] were significantly shorter, and the propofol dosage [(11.8±1.8) mg/kg vs. (15.9±4.6) mg/kg], remifentanil dosage [(10.9±4.7) μg/kg vs. (14.1±3.6) μg/kg] were significantly less in the G group, and there was no difference of rocuronium dosage in the two groups. Compared with the C group the incidence of intraoperative hypotension [10%(3/30) vs. 30%(9/30)], bradycardia [16.7%(5/30) vs. 20%(6/30)] and postoperative agitation [6.7%(2/30) vs. 23.3%(7/30)] were significantly lower in the C group. The postoperative sore throat score at the end of operation, 4 h, 8 h, 12 h and 24 h after operation in the G group were significantly lower than in the C group respectively [0 (0, 1) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (1, 2), 0 (0, 0) vs. 1 (0.75, 1), 0 (0, 0) vs. 1 (0, 1)].@*CONCLUSION@#Dexamethasone combined with oxybuprocaine hydrochloride gel was effective and feasible on the prevention of postoperative sore throat after nasal endoscopy.

Uso de Remifentanilo en pacientes COVID-19 críticos hospitalizados con ventilación mecánica / Use of Remifentanil in critical COVID-19 patients hospitalized with mechanical ventilation

ANTECEDENTES: El objetivo del presente informe es: Describir el proceso para la elaboración de recomendaciones por el grupo de trabajo designado por el Ministerio de Salud, en adelante denominado grupo de trabajo. Trasladar las Recomendaciones efectuadas por dicho grupo de trabajo en atención al uso de remifentanilo en pacientes COVID-19 críticos hospitalizados con ventilación mecánica, según la pregunta PICO (P: Población, I:Intervención, C:Comparador, O: Outcome o desenlaces) priorizada por el grupo de trabajo. La metodología considerada para arribar a la recomendación fue el Marco de Evidencia a la Decisión/Recomendación (EtD) desarrollado por el Grupo de Trabajo GRADE (1,2). ANALISIS: Formulación de la pregunta: En personas con COVID-19 crítico en ventilación mecánica invasiva ¿Qué analgésico opioide endovenoso debe utilizarse: Remifentanilo vs fentanilo? ¿Cuál es la dosis que debe administrarse? Identificación de la evidencia para la pregunta PICO: Se siguieron las orientaciones establecidas en el documento interno de UNAGESP: Orientaciones para el soporte metodológico otorgado al grupo de trab

The efficacy of esmolol, remifentanil and nitroglycerin in controlled hypotension for functional endoscopic sinus surgery / Eficácia do esmolol, remifentanil e nitroglicerina na hipotensão controlada para cirurgia sinusal endoscópica funcional

Abstract Introduction Controlled hypotension is a reversible procedure in which the patient's baseline mean arterial blood pressure is reduced by 30% and sustained at 60-70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. Objectives The purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. Methods The research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon's satisfaction. Results Between May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15-51), 43.0 mL (21-105) and 40.0 mL (26-97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon's satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). Conclusion Less volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients' characteristics and advantages/disadvantages of the drugs.

Resumo Introdução Hipotensão controlada é um procedimento reversível no qual a pressão arterial média basal do paciente é reduzida em 30% e mantida em 60-70 mmHg durante o procedimento. Isso diminui a perda de sangue e propicia um campo cirúrgico limpo durante os procedimentos. Objetivo Comparar agentes usados para hipotensão controlada: esmolol, remifentanil e nitroglicerina em cirurgia sinusal endoscópica funcional, em termos de alterações hemodinâmicas e impactos na eficácia cirúrgica. Método O estudo foi feito como de coorte. Pacientes submetidos à cirurgia sinusal endoscópica funcional foram randomizados em 3 grupos. A hipotensão controlada foi feita com remifentanil (Grupo R), esmolol (Grupo E) e nitroglicerina (Grupo R). A eficácia dos medicamentos foi testada com a comparação do período de tempo com a pressão arterial média desejada, a quantidade de anestésicos usados, o escore de sangramento no campo cirúrgico e a satisfação do cirurgião. Resultados Entre maio e dezembro de 2015, 60 pacientes foram incluídos e randomizados igualmente nos três grupos de estudo. A mediana do período com a pressão arterial desejada foi menor no Grupo R quando comparado ao Grupo E (p = 0,01) e Grupo N (p = 0,14). A quantidade de anestésicos voláteis usados foi de 25,0 mL (15 ± 51), 43,0 mL (21 ± 105) e 40,0 mL (26 ± 97) nos Grupos R, E e N, respectivamente (p < 0,001). Houve mais sangramento com nitroglicerina e escores de sangramento no campo cirúrgico foram menores no Grupo R quando comparados com esmolol (p = 0,001) e nitroglicerina (p < 0,001). A análise dos escores da satisfação do cirurgião concluiu que os cirurgiões estavam mais satisfeitos com o grupo R (100%) quando comparados ao grupo E (60%) e o grupo N (30%) (p < 0,001). Conclusão Agente menos volátil, pouco tempo para obter a hipotensão controlada, pressão arterial estável, menor escore de sangramento no campo cirúrgico e período de pressão arterial desejada curto foram considerados como vantagens do remifentanil. Menor custo, eficácia de obtenção da pressão arterial média desejada e menos complicações pós-operatórias foram as vantagens da nitroglicerina. Nos procedimentos de cirurgia sinusal endoscópica funcional, os agentes apropriados para obtenção de hipotensão controlada devem ser selecionados de acordo com as características dos pacientes e as vantagens/desvantagens dos fármacos.

Use of a Combined Anaesthetic Technique and Minimally Invasive Hemodynamic Monitoring in a Primigravid with Uncorrected Tetralogy of Fallot for Caesarean Section

@#<p style="text-align: justify;">Tetralogy of Fallot (TOF) in pregnancy is a rare occurrence which poses a high risk for detrimental effects on both mother and fetus. This paper reports a 21-year-old primigravid diagnosed with uncorrected TOF who had a successful caesarean section at 32 weeks of gestation. To address the hemodynamic challenges, the anaesthetic management involved the use of a minimally invasive hemodynamic monitor, controlled mechanical ventilation and a combined technique of intravenous anaesthesia using remifentanil and lumbar epidural anaesthesia using levobupivacaine.</p>

Maximum dose of continuous infusion of mivacurium for thyroid surgery under total intravenous anesthesia: a sequential trial of monitoring neurological function in 30 patients / 南方医科大学学报

OBJECTIVE@#To investigate the maximum dose of continuous mivacurium infusion for intraoperative neuromonitoring (IONM) and observe the adverse reactions during thyroid surgery under total intravenous anesthesia (TIVA).@*METHODS@#Thirty patients undergoing IONM during thyroid surgery received continuous infusion of mivacurium at the initial rate of 14.97 μg · kg@*RESULTS@#The EC@*CONCLUSIONS@#In patients undergoing thyroid surgery under TIVA, the EC

Effect of pre-administered flurbiprofen axetil on the EC50 of propofol during anesthesia in unstimulated patients: a randomized clinical trial / Efeito da pré‐ administração de flurbiprofeno axetil na CE50 do propofol durante anestesia em pacientes não estimulados: estudo clínico randomizado

Abstract Background and objectives Preoperative use of flurbiprofen axetil (FA) is extensively adopted to modulate the effects of analgesia. However, the relationship between FA and sedation agents remains unclear. In this study, we aimed to investigate the effects of different doses of FA on the median Effective Concentration (EC50) of propofol. Methods Ninety-six patients (ASA I or II, aged 18-65 years) were randomly assigned into one of four groups in a 1:1:1:1 ratio. Group A (control group) received 10 mL of Intralipid, and groups B, C and D received 0.5 mg.kg−1, 0.75 mg.kg−1 and 1 mg.kg−1 of FA, respectively, 10 minutes before induction. The depth of anesthesia was measured by the Bispectral Index (BIS). The "up-and-down" method was used to calculate the EC50 of propofol. During the equilibration period, if BIS ≤ 50 (or BIS > 50), the next patient would receive a 0.5 µg.mL−1-lower (or -higher) propofol Target-Controlled Infusion (TCI) concentration. The hemodynamic data were recorded at baseline, 10 minutes after FA administration, after induction, after intubation and 15 minutes after intubation. Results The EC50 of propofol was lower in Group C (2.32 µg.mL−1, 95% Confidence Interval [95% CI] 1.85-2.75) and D (2.39 µg.mL−1, 95% CI 1.91-2.67) than in Group A (2.96 µg.mL−1, 95% CI 2.55-3.33) (p = 0.023, p = 0.048, respectively). There were no significant differences in the EC50 between Group B (2.53 µg.mL−1, 95% CI 2.33-2.71) and Group A (p > 0.05). There were no significant differences in Heart Rate (HR) among groups A, B and C. The HR was significantly lower in Group D than in Group A after intubation (66 ± 6 vs. 80 ± 10 bpm, p < 0.01) and 15 minutes after intubation (61 ± 4 vs. 70 ± 8 bpm, p < 0.01). There were no significant differences among the four groups in Mean Arterial Pressure (MAP) at any time point. The MAP of the four groups was significantly lower after induction, after intubation, and 15 minutes after intubation than at baseline (p < 0.05). Conclusion High-dose FA (0.75 mg.kg−1 or 1 mg.kg−1) reduces the EC50 of propofol, and 1 mg.kg−1 FA reduces the HR for adequate anesthesia in unstimulated patients. Although this result should be investigated in cases of surgical stimulation, we suggest that FA pre-administration may reduce the propofol requirement when the depth of anesthesia is measured by BIS.

Resumo Justificativa e objetivos A administração pré‐operatória de Flurbiprofeno Axetil (FA) é amplamente usada para a modulação da analgesia. No entanto, a relação entre FA e fármacos sedativos permanece obscura. Neste estudo, nosso objetivo foi investigar os efeitos de diferentes doses de FA na Concentração Efetiva mediana (CE50) do propofol. Métodos Noventa e seis pacientes (ASA I ou II, com idades de 18-65 anos) foram alocados aleatoriamente em quatro grupos na proporção de 1:1:1:1. Dez minutos antes da indução, o Grupo A (grupo controle) recebeu 10 mL de Intralipid, enquanto os grupos B, C e D receberam FA na dose de 0,5 mg.kg‐1; 0,75 mg.kg‐1 e 1 mg.kg‐1, respectivamente. A profundidade da anestesia foi medida pelo Índice Bispectral (BIS). O método up‐and‐down foi usado para calcular a CE50 do propofol. Durante o período de equilíbrio, se o valor do BIS fosse ≤ 50 ou BIS > 50, o próximo paciente tinha a infusão de propofol ajustada para uma concentração alvo‐controlada 0,5 µg.mL‐1 inferior ou superior, respectivamente. Os dados hemodinâmicos foram registrados no início do estudo, 10 minutos após a administração de FA, após a indução, após a intubação e 15 minutos após a intubação. Resultados A CE50 do propofol foi menor no Grupo C (2,32 µg.mL‐1, Intervalo de Confiança de 95% [95% IC] 1,85-2,75) e D (2,39 µg.mL‐1, 95% IC 1,91-2,67) do que no Grupo A (2,96 µg.mL‐1; 95% IC 2,55-3,33) (p = 0,023, p = 0,048, respectivamente). Não houve diferenças significantes na CE50 entre o Grupo B (2,53 µg.mL‐1, 95% IC 2,33-2,71) e o Grupo A (p > 0,05). Não houve diferenças significantes na Frequência Cardíaca (FC) entre os grupos A, B e C. A FC foi significantemente menor no grupo D do que no grupo A após a intubação (66 ± 6 vs. 80 ± 10 bpm, p < 0,01) e 15 minutos após a intubação (61 ± 4 vs. 70 ± 8 bpm, p < 0,01). Não houve diferenças significantes entre os quatro grupos na Pressão Arterial Média (PAM) em qualquer momento. A PAM dos quatro grupos foi significantemente menor após a indução, após a intubação e 15 minutos após a intubação do que na linha de base (p < 0,05). Conclusão FA em altas doses (0,75 mg.kg‐1 ou 1 mg.kg‐1) reduz a CE50 do propofol, e 1 mg.kg‐1 de FA reduz a FC durante níveis adequados de anestesia em pacientes não estimulados. Embora esse resultado deva ser investigado na presença de estimulação cirúrgica, sugerimos que a pré‐administração de FA pode reduzir a necessidade de propofol durante anestesia cuja profundidade seja monitorada pelo BIS.

Effect of palonosetron, ondansetron and dexamethasone in the prevention of postoperative nausea and vomiting in video cholecystectomy with total venous anesthesia with propofol-remifentanil - randomized clinical trial / Efeito da palonosetrona, ondansetrona e dexametasona na prevenção de náusea e vômito pós-operatório em videocolecistectomia com anestesia venosa total com propofol-remifentanil - ensaio clínico randomizado duplo cego

Abstract Introduction and objectives: The incidence of Postoperative Nausea and Vomiting (PONV) after video cholecystectomy is high. Progress in pharmacological PONV prophylaxis includes a new generation of 5-HT3 antagonists. This study aims to assess the effect of the 5-HT3 antagonist in postanesthetic antiemetic management of patients submitted to laparoscopic cholecystectomy with total intravenous anesthesia. Methods: Sixty individuals who underwent video cholecystectomy were randomized into three groups of 20 individuals according to the treatment administered: 0.125 mg of palonosetron (Group 1); 4 mg of ondansetron associated with 4 mg of dexamethasone (Group 2); 4 mg of dexamethasone (Group 3). General intravenous anesthesia was performed with propofol, remifentanil and rocuronium. The group to which the participant belonged was concealed from the investigator who assessed drug effect. PONV was assessed using the Rhodes Scale at 12 and 24 hours after surgery. Rescue medication was 0.655 to 1.5 mg of droperidol. Results: Group 1 presented a lower incidence of PONV and required less rescue medication in the first postoperative hour. There was no significant difference among the three groups regarding PONV incidence in the first 12 postoperative hours. Groups 1 and 2 were superior to Group 3 regarding the control of PONV from 12 to 24 hours, and after rescue medication from 12 to 24 hours. Group 1 showed significantly superior nausea control in the first 12 postoperative hours. Conclusions: The present study showed evidence that palonosetron is superior to the drugs compared regarding a protracted antiemetic effect and less requirement of rescue drugs, mainly related to its ability to completely inhibit the uncomfortable symptom of nausea.

Resumo Justificativa e objetivo: Náuseas e Vômitos no Pós-Operatório (NVPO) têm alta incidência após videocolecistectomia. Avanços na profilaxia farmacológica de NVPO incluem a nova geração de antagonista 5-HT3. O objetivo deste estudo foi avaliar o efeito do antagonista 5-HT3 no controle antiemético pós-anestésico em videocolecistectomia com anestesia venosa total. Método: Estudo realizado no HC-UFU (Hospital Terciário). Sessenta indivíduos submetidos a videocolecistectomia foram randomizados em três grupos de igual número, sendo administrados 0,125 mg de palonosetrona (Grupo 1); 4 mg de ondasetrona e 4 mg de dexametasona (Grupo 2); ou 4 mg de dexametasona (Grupo 3). A anestesia geral venosa foi realizada com propofol, remifentanil e rocurônio. O avaliador do efeito da droga desconhecia o grupo ao qual o indivíduo pertencia. NVPO foi avaliada aplicando a Escala de Rhodes após 12 e 24 horas do término da cirurgia. Para resgate terapêutico, foi estabelecido 0,655−1,5 mg de droperidol. Resultado: Observou-se no Grupo 1 menor incidência de NVPO e de resgate terapêutico na primeira hora de PO. Não foi observada diferença significativa entre os três grupos com relação a ocorrência de NVPO nas primeiras 12 horas de pós-operatório. Os grupos 1 e 2 foram superiores ao Grupo 3 no que se refere ao controle de NVPO de 12 a 24 horas e após o resgate de 12−24 horas. Observou-se que o controle de náuseas nas primeiras 12 horas de pós-operatório do Grupo 1 foi significantemente superior. Conclusão: O presente estudo mostrou evidências da superioridade da palonosetrona às demais drogas empregadas no que se refere ao efeito antiemético prolongado e menor necessidade de resgate, principalmente na capacidade de inibir completamente o desconfortável sintoma de náusea.

Use of video laryngoscope for tracheal intubation in patient with oral cavity mass: case report / Uso de videolaringoscópio para intubação traqueal em paciente com massa tumoral na cavidade oral: relato de caso

Abstract Background and objectives When planning the management of a predicted difficult airway, it is important to determine which strategy will be followed. Video laryngoscopy is a major option in scenarios with factors suggesting difficult airway access. It is also indicated in rescue situations, when there is tracheal intubation failure with direct laryngoscopy. The objective of the present report was to show the efficacy of using the video laryngoscope as the first device for a patient with a large tumor that occupied almost the entire anterior portion of the oral cavity. Case report An 85 year-old male patient, 162 cm, 70 kg, ASA Physical Status II, Mallampati IV classification, was scheduled for resection of an angiosarcoma located in the right maxillary sinus that invaded much of the hard palate and the upper portion of the oropharynx. He was conscious and oriented, with normal blood pressure, heart and respiratory rates and, despite the large tumor in the oral cavity, he showed no signs of respiratory failure or airway obstruction. After intravenous cannulation and monitoring, sedation was performed with 1 mg of intravenous midazolam, and a nasal cannula was placed to provide oxygen, with a flow of 2 L min−1. Then, the target-controlled infusion of remifentanil with an effect site concentration of 2 ng mL−1 was initiated, according to Minto's pharmacokinetic model. Ventilation was maintained spontaneously during airway handling. A trans-cricothyroid block was performed, with 8 mL of 1% lidocaine solution injected into the tracheal lumen. Slight bleeding did not prevent the use of an optical method for performing tracheal intubation. The entire oral cavity was sprayed with 1% lidocaine. The McGraph video laryngoscope with the difficult intubation blade was used, and an armored tube with a guide wire inside was used for tracheal intubation, performed on the first attempt with appropriate glottis visualization. Conclusion The video laryngoscope occupies a prominent position in cases in which access to the airway is difficult. In the present case it was useful. It can be used as first choice or as a rescue technique. The video laryngoscope is an appropriate alternative and should be available for facing the ever-challenging difficult airway patient.

Resumo Justificativa e objetivos No planejamento da abordagem a uma via aérea difícil prevista, é importante determinar qual será a estratégia a ser seguida. A videolaringoscopia é uma ótima opção em situações em que existam fatores indicadores de dificuldade de acesso à via aérea. Também é indicada em situações de resgate, quando houve insucesso na tentativa de intubação com a laringoscopia direta. O objetivo deste relato é mostrar a eficácia da utilização do videolaringoscópio como primeiro dispositivo diante de paciente com grande tumor que ocupava quase a totalidade da porção anterior da cavidade oral. Relato do caso Paciente com 85 anos, sexo masculino, 162 cm, 70 kg, estado físico ASA II, classificação de Mallampati IV, foi escalado para a ressecção de um angiossarcoma localizado no seio maxilar direito que invadia grande parte do palato duro e da porção superior da orofaringe. Apresentava-se lúcido, consciente e orientado, com valores de pressão arterial, frequência cardíaca e respiratória normais e, apesar do grande tumor na cavidade oral, não apresentava qualquer sinal de insuficiência respiratória ou de obstrução das vias aéreas. Após venóclise, foi feita monitorização e sedação com 1 mg de midazolam, por via venosa, e colocado cateter nasal para administração de oxigênio, com fluxo de 2 L.min-1. Em seguida, foi iniciada a infusão alvo-controlada de remifentanil com concentração efeito de 2 ng.mL-1 segundo o modelo farmacocinético de Minto. A ventilação foi mantida em espontânea durante a manipulação da via aérea. Foi realizado bloqueio transcricotireóideo, sendo injetados 8 mL de solução de lidocaína a 1% na luz traqueal. Um pequeno sangramento não impediu que um método óptico fosse utilizado para realizar a intubação traqueal. Toda a cavidade oral recebeu o spray de lidocaína tópica a 1%. Foi utilizado o videolaringoscópio McGraph com a lâmina de intubação difícil, e um tubo aramado com fio guia no seu interior, foi utilizado para a intubação traqueal, que foi realizada na primeira tentativa, com boa visualização da glote. Conclusão O videolaringoscópio ocupa uma posição de destaque nos casos em que o acesso à via aérea é difícil. No presente caso, a sua utilização foi útil. Ele pode ser utilizado como primeira opção ou como técnica de resgate. Nas condições sempre preocupantes diante de um paciente com via aérea difícil, o videolaringoscópio deve estar disponível, constituindo-se uma boa opção.

Anestesia total intravenosa con remifentanilo vs fentanilo como base analgésica en cirugía torácica electiva / Intravenous total anesthesia with remifentanil and fentanyl as analgesic base in elective thoracic surgery

Introducción: Mantener una oxigenación adecuada durante la ventilación a un solo pulmón es el problema fundamental al que se enfrenta el anestesiólogo durante la cirugía torácica, es por ello que se mantiene una constante búsqueda del método anestésico ideal que ayude a lograr dicho objetivo. Objetivos: Evaluar los resultados de dos técnicas de anestesia total intravenosa con remifentanilo y fentanilo como base analgésica e identificar la aparición de complicaciones durante la intervención quirúrgica. Métodos: Se realizó un estudio causiexperimental prospectivo, en el Hospital Docente Clínico Quirúrgico Dr. Salvador Allende, entre enero 2013 a diciembre 2015 en 40 pacientes ASA II o III que requirieron procedimientos intratorácicos. Estos se dividieron en dos grupos. A (remifentanilo-propofol) y B (fentanilo-propofol). Se estudiaron variables hemodinámicas, de oxigenación durante la ventilación unipulmonar, el tiempo de recuperación anestésica (ventilación espontánea, apertura ocular, extubación) y la analgesia posoperatoria. Resultados: No existieron variaciones significativas en la hemodinamia, ni en la oxigenación de los enfermos con el empleo de ambas técnicas anestésicas; sin embargo, el despertar y recuperación posoperatoria a corto plazo fue mejor en el grupo A. La intensidad del dolor posoperatorio según la escala visual análoga fue menor en el grupo B. Conclusiones: Ambas técnicas son efectivas para procedimientos quirúrgicos torácicos. Con mínima interferencia en la hemodinámia y parámetros de oxigenación(AU)

Introduction: Maintaining adequate oxygenation during single-lung ventilation is a fundamental concern faced by the anesthesiologist during thoracic surgery; therefore, a constant search is maintained for the ideal anesthetic method that helps achieve this goal is maintained. Objectives: To evaluate the outcomes of two total intravenous anesthesia techniques with remifentanil and fentanyl as analgesic base and to identify the onset of complications during surgery. Methods: A prospective and quasi-experimental study was carried out at Dr. Salvador Allende Clinical-Surgical Hospital, between January 2013 and December, with 40 ASA II or III patients who required intrathoracic procedures. These were divided into two groups: A (remifentanil-propofol) and B (fentanyl-propofol). Hemodynamic variables and others of oxygenation during one-lung ventilation were studied, together with anesthetic recovery time (spontaneous ventilation, ocular opening, extubation) and postoperative analgesia. Results: There were no significant variations in the hemodynamics or oxygenation of patients with the use of both anesthetic techniques; however, awakening and short-term postoperative recovery was better in group A. Postoperative pain intensity, based on the analogue-visual scale, was lower in group B. Conclusion: Both techniques are effective for thoracic surgical procedures, with minimal effect in hemodynamics and oxygenation parameters(AU)

Effects of remifentanil on awakening of propofol sedated patients submitted to upper gastrointestinal endoscopy: a randomized clinical trial / Efeitos do remifentanil sobre despertar de pacientes sedados com propofol para endoscopia digestiva alta: estudo clínico randomizado

Abstract Background and objectives: Sedation for endoscopic procedures aims to provide high quality sedation, lower risks, short recovery time, superior recovery quality and absence of side effects, seeking high patient level of satisfaction. The goal of the study was to assess administration of remifentanil combined with propofol regarding the effects of the drug association during sedation and recovery for patients submitted to upper gastrointestinal diagnostic endoscopy. Method: One hundred and five patients were assessed, randomly divided into three groups of 35 patients. The Control Group was sedated with propofol alone. Study Group 1 was sedated with a fixed dose of 0.2 µg.kg−1 remifentanil combined with propofol. Study Group 2 was sedated with 0.3 µg.kg−1 remifentanil combined with propofol. We assessed the quality of sedation, hemodynamic parameters, incidence of significant hypoxemia, time for spontaneous eye opening, post-anesthetic recovery time, quality of post-anesthetic recovery, presence of side effects and patient satisfaction. Results: Study Group 1 showed better quality of sedation. The groups in which remifentanil was administered combined with propofol showed shorter eye-opening time and shorter post-anesthetic recovery time compared to the control group. The three groups presented hemodynamic changes at some of the moments assessed. The incidence of significant hypoxemia, the quality of post-anesthetic recovery, the incidence of side effects and patient satisfaction were similar in the three groups. Conclusions: The combination of propofol with remifentanil at a dose of 0.2 µg.kg−1 was effective in improving the quality of sedation, and at doses of 0.2 µg.kg−1 and 0.3 µg.kg−1 reduced the time to spontaneous eye opening and post-anesthetic recovery in comparison to sedation with propofol administered alone.

Resumo Justificativa e objetivos: A sedação para procedimentos endoscópicos pretende fornecer boa qualidade de sono, menores riscos, tempo de recuperação mais curto, qualidade de recuperação superior e ausência de efeitos colaterais, buscando um elevado nível de satisfação dos pacientes. O objetivo deste estudo foi avaliar a influência da associação do remifentanil ao propofol e seus efeitos durante a sedação e a recuperação em exames de endoscopia digestiva alta diagnóstica. Método: Foram avaliados 105, divididos aleatoriamente em três grupos de 35 pacientes. O Grupo Controle foi sedado apenas com o uso de propofol, o Grupo de Estudo 1 foi sedado com uso de remifentanil em dose fixa de 0,2 µg.Kg-1 associado ao propofol. E o Grupo de Estudo 2 foi sedado com o uso de remifentanil em dose fixa de 0,3 µg.Kg-1 associado ao propofol. Foram avaliadas a qualidade da sedação, comportamento hemodinâmico, incidência de hipoxemia significativa, tempo para abertura ocular espontânea, tempo de recuperação pós-anestésica, qualidade da recuperação pós-anestésica, presença de efeitos colaterais e satisfação do paciente. Resultado: O Grupo de Estudo 1 apresentou melhor qualidade de sedação. Os grupos em que se associou o remifentanil apresentaram tempo para abertura ocular e tempo de recuperação anestésica mais curtos em relação ao grupo controle. Os três grupos apresentaram alterações hemodinâmicas em algum dos momentos avaliados. A incidência de hipoxemia significativa, a qualidade da recuperação pós-anestésica, a incidência de efeitos colaterais e a satisfação dos pacientes foram similares nos três grupos. Conclusão: Conclui-se que a associação do remifentanil na dose de 0,2 µg.kg-1 mostrou-se efetivo na melhora da qualidade da sedação, e nas doses 0,2 µg.kg-1 e de 0,3 µg.kg-1 reduziu o tempo de abertura ocular espontânea e o tempo de recuperação pós-anestésica dos pacientes em relação a sedação apenas com propofol.

Anestesia intravenosa total: Propofol/remifentanil vs. midazolam/remifentanil en cirugía torácica / Total intravenous anesthesia: propofol/remifentanil vs midazolam/remifentanil in thoracic surgery

Introducción: Las técnicas de administración de anestesia en cirugía torácica han experimentado gran evolución y mayor fundamento científico. La anestesia intravenosa total basada en la analgesia favorece a que el período perioperatorio transcurra sin dolor y la recuperación sin complicaciones. Objetivo: Comparar la efectividad y seguridad de dos técnicas de anestesia intravenosa total en cirugía torácica electiva con remifentanilo como base analgésica. Métodos: Estudio causiexperimental, prospectivo realizado en el Hospital Docente Clínico Quirúrgico Dr. Salvador Allende, en el período comprendido entre enero de 2013 a enero de 2015, en 45 pacientes, programados para cirugía torácica electiva, divididos en dos grupos según hipnótico utilizado. Grupo A: Propofol/Remifentanil y Grupo B: Midazolam/Remifentanil. Se evaluaron variables hemodinámicas en diferentes momentos del período intraoperatorio. Variables de oxigenación (PaO2 y SaO2) durante la ventilación unipulmonar y los tiempos de recuperación anestésica. Resultados: Predominaron los pacientes mayores de 60 años en los dos grupos, con estado físico ASA III. No hubo diferencias en la oxigenación arterial entre los grupos. Hubo disminución de la tensión arterial sistólica en el grupo A sin diferencias significativas. La recuperación de la anestesia fue significativamente más demorada en el grupo B. Conclusiones: La técnica de anestesia intravenosa total con remifentanil como base analgésica asociado a propofol resultó segura y efectiva en pacientes operados de cirugía torácica(AU)

Introduction: Anesthesia administration techniques in thoracic surgery have undergone great evolution and greater scientific foundation. Total intravenous anesthesia based on analgesia favors the perioperative period without pain and recovery without complications. Objective: To compare the effectiveness and safety of two techniques of total intravenous anesthesia in elective thoracic surgery with remifentanil as an analgesic base. Methods: Prospective and causiexperimental study carried out at Dr. Salvador Allende Clinical-Surgical Teaching Hospital, in the period from January 2013 to January 2015, with 45 patients scheduled for elective thoracic surgery, who were divided into two groups according to the hypnotic drug used. Group A: propofol/remifentanil, and group B: midazolam/remifentanil. Hemodynamic variables were evaluated at different times during the intraoperative period. Oxygenation variables (PaO2 and SaO2) during unipulmonary ventilation and anesthetic recovery times. Results: Patients older than 60 years predominated in the two groups, with a physical status of ASA III. There were no differences in arterial oxygenation between the groups. There was a decrease in systolic blood pressure in group A without significant differences. The recovery of anesthesia was significantly more delayed in group B. Conclusions: The total intravenous anesthesia technique with remifentanil as an analgesic base associated with propofol was safe and effective in patients undergoing thoracic surgery(AU)

Feasibility of non-intubated anesthesia and regional block for thoracoscopic surgery under spontaneous respiration: a prospective cohort study

Data about the feasibility and safety of thoracoscopic surgery under non-intubated anesthesia and regional block are limited. In this prospective study, 57 consecutive patients scheduled for thoracoscopic surgery were enrolled. Patients were sedated with dexmedetomidine and anesthetized with propofol and remifentanil. Ropivacaine was used for intercostal nerve and paravertebral block. Lidocaine was used for vagal block. The primary outcomes were mean arterial pressure (MAP), heart rate (HR), oxygen saturation, and end-tidal carbon dioxide partial pressure (ETCO2) at T0 (pre-anesthesia), T1 (immediately after laryngeal mask/nasopharyngeal airway placement), T2 (immediately after skin incision), T3 (10 min after opening the chest), T4 (end of surgery), and T5 (immediately after laryngeal mask/nasopharyngeal airway removal). One patient required conversion to intubation, 15 developed intraoperative hypotension, and two had hypoxemia. MAP at T0 and T5 was higher than at T1-T4; MAP at T3 was lower (P<0.05 vs other time points). HR at T0 and T5 was higher (P<0.05 vs other time points). ETCO2 at T2 and T3 was higher (P<0.05 vs other time points). Arterial pH, PCO2, and lactic acid at T1 differed from values at T0 and T2 (P<0.05). The Quality of Recovery-15 (QoR-15) score at 24 h was lower (P<0.05). One patient experienced dysphoria during recovery. Thoracoscopic surgery with regional block under direct thoracoscopic vision is a feasible and safe alternative to conventional surgery under general anesthesia, intubation, and one-lung ventilation.

Anestesia para reparación antenatal de mielomeningocele: Presentación de un caso / Anesthesia for myelomenigocele antenatal repair: Case report

INTRODUCTION: The advance in the methods of prenatal diagnosis and surgical techniques have allowed the development of fetal surgery, achieving identification and early treatment of anomalies invalidating extrauterine life. Myelomeningocele (MMC) is the most frequent neural tube defect and its intrauterine correction has demonstrated benefits. OBJECTIVE: To publicize the anesthetic management of a prenatal correction of MMC performed in a public hospital in Chile. CASE REPORT: 31-year-old woman, pregnancy of 25 weeks of gestational age, fetus carrying MMC lumbosacral, who underwent open correction. Procedure performed with incidents under general anesthesia with remifentanil and sevoflorane MAC in 2 and tocolytic prophylaxis. At 48 hours post operative, he presented an acute pulmonary edema compatible (EPA), which was successfully resolved with depletive therapy for 24 hours in the Intensive Care Unit, without the need for mechanical ventilation or use of vasoactive drugs. Discharged one week later in good condition, with interruption of pregnancy by elective caesarean section at 37 weeks, with a newborn without stigmas of neurological sequelae. CONCLUSIONS: The mother-fetus binomial is a challenge for the anesthetist. In intrauterine surgery the need for knowledge about the pharmacology of tocolytics, placental uterine physiology and the complications of the procedure are added.

INTRODUCCIÓN: El avance en los métodos de diagnóstico prenatal y las técnicas quirúrgicas han permitido el desarrollo de la cirugía fetal, logrando identificación y tratamiento precoz de anomalías invalidantes para la vida extrauterina. El mielomeningocele (MMC) es el defecto del tubo neural más frecuente y su corrección intrauterina tiene beneficios demostrados. OBJETIVO: Dar a conocer el manejo anestésico de una corrección prenatal de MMC realizada en un hospital público de Chile. CASO CLÍNICO: Mujer de 31 años, embarazo de 25 semanas de edad gestacional, feto portador de MMC lumbosacro, que se sometió a una corrección por vía abierta. Procedimiento realizado con incidentes bajo anestesia general con remifentanilo y sevoflorano MAC en 2 y profilaxis tocolítica. A las 48 horas postoperatorias presentó cuadro compatible con edema pulmonar agudo (EPA), que se resolvió exitosamente con terapia depletiva por 24 horas en Unidad de Cuidados Intensivos, sin necesidad de ventilación mecánica ni uso de drogas vasoactivas. Dada de alta una semana después en buenas condiciones. El embarazo se interrumpió por cesárea electiva a las 37 semanas, con un recién nacido sin estigmas de secuela neurológica. CONCLUSIONES: El binomio madre-feto es un reto para el anestesista. En cirugía intraútero se suma la necesidad de conocimientos sobre la farmacología de los tocolíticos, fisiología útero placentaria y las complicaciones propias del procedimiento.

Comparison of anesthesia effects between closed / 中南大学学报(医学版)

OBJECTIVES@#Bispectral index (BIS) can reflect the depth of propofol sedation. This study aims to compare the anesthetic satisfaction, anesthetic dose, and hemodynamic changes between closed-loop target controlled infusion (CLTCI) and open-loop target controlled infusion (OLTCI) during abdominal surgery.@*METHODS@#From December 2016 to December 2018, 70 patients undergoing abdominal surgery under general anesthesia were selected in Beijing Hospital, including 51 males and 19 females, at the age from 49 to 65 years old. They were classified as grade I-II by the American Society of anesthesiologists (ASA) and were randomly divided into the CLTCI group and the OLTCI group (@*RESULTS@#In the induction stage, the percentage of adequate anesthesia time in the CLTCI group was higher than that in the OLTCI group, and the percentage of deep anesthesia time in the CLTCI group was significantly lower than that in the OLTCI group (both @*CONCLUSIONS@#Compared with propofol OLTCI, anesthesia with propofol CLTCI under BIS guidance can maintain a more appropriate depth of anesthesia sedation and more stable hemodynamics.

The effects of remifentanil used during cesarean section on oxidative stress markers in correlation with maternal hemodynamics and neonatal outcome: a randomized controlled trial / Os efeitos do remifentanil sobre os marcadores do estresse oxidativo durante a cesariana, em correlação com a hemodinâmica materna e o desfecho neonatal: um estudo randômico controlado

Abstract Background and objective: Remifentanil is used to attenuate maternal hemodynamic response to intubation and surgical stress during Induction-Delivery period of cesarean section. The goal was to compare the effects of two remifentanil dosing regimens on oxidative stress level, in correlation with its hemodynamic and neonatal effects. Methods: Fifty-one patients, 17 per group, enrolled for elective cesarean section were randomly divided by computer-generated codes into three parallel groups: (A) patients received a 1 µg.kg-1 remifentanil bolus immediately before induction, followed by 0.15 µg.kg-1.min-1 infusion, that was stopped after skin incision; (B) patients received a 1 µg.kg-1 remifentanil bolus immediately before induction; (C) (control), patients did not receive remifentanil until delivery. Maternal venous blood samples were taken at basal time, at extraction and 30 minutes after the end of operation for spectrophotometrical determination of malondialdehyde and advanced oxidation protein products concentration. The same was conducted for umbilical venous sample. Results: Systolic blood pressure and heart rate remained significantly lower in group A compared to B and C during entire Induction-Delivery period (p < 0.001, p = 0.02 after intubation; p = 0.006, p = 0.03 after skin incision; p = 0.029, p = 0.04 after extraction; respectively). Malondialdehyde concentration was lower at time of extraction in maternal blood in group A compared to B and C (p = 0.026). All neonatal Apgar scores were ≥ 8 and umbilical acid-base values within normal range. Conclusions: The remifentanil dosing regimen applied in group A significantly attenuated lipid peroxidation and maternal hemodynamic response during entire I-D period, without compromising neonatal outcome.

Resumo Justificativa e objetivo: O remifentanil é usado para atenuar a resposta hemodinâmica materna à intubação e ao estresse cirúrgico durante o intervalo indução-parto cesariana. O objetivo foi comparar os efeitos de dois regimes posológicos de remifentanil sobre o nível de estresse oxidativo, em correlação com seus efeitos na hemodinâmica materna e no neonato. Métodos: Mediante códigos gerados por computador, 51 pacientes (17 por grupo) programadas para cesariana eletiva foram randomicamente divididas em três grupos paralelos (A, B e C). No Grupo A, as pacientes receberam remifentanil em bolus de 1 µg.kg-1 imediatamente antes da indução, seguido por infusão de 0,15 µg.kg-1.min-1 que foi interrompida após a incisão da pele; no Grupo B, as pacientes receberam remifentanil em bolus de 1 µg.kg-1 imediatamente antes da indução; no Grupo C (controle), as pacientes não receberam remifentanil até o parto. Amostras de sangue venoso materno foram colhidas no momento basal, na extração do feto e 30 minutos após o término da operação para determinar espectrofotometricamente as concentrações do malondialdeído e dos produtos proteicos de oxidação avançada. O mesmo foi feito para a coleta das amostras de sangue venoso umbilical. Resultados: A pressão arterial sistólica e a frequência cardíaca permaneceram significativamente menores no Grupo A, comparado aos grupos B e C, durante todo o intervalo indução-parto (p < 0,001, p = 0,02 após a intubação; p = 0,006, p = 0,03 após a incisão da pele; p = 0,029, p = 0,04 após a extração do feto, respectivamente). No momento da extração do feto, a concentração do malondialdeído foi menor no sangue materno do Grupo A, comparado aos grupos B e C (p = 0,026). Todos os escores de Apgar neonatais foram ≥ 8 e os valores da avaliação ácido-base do cordão umbilical estavam dentro da faixa normal. Conclusões: O regime posológico de remifentanil aplicado ao Grupo A atenuou de modo significativo a peroxidação lipídica e a resposta hemodinâmica materna durante todo o intervalo indução-parto, sem comprometer o desfecho neonatal.

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

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

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

Analgesia Nociception Index: assessment of acute postoperative pain / Índice de Analgesia/Nocicepção: avaliação da dor aguda pós-operatória

Abstract Background and objectives Patient self-rating based scales such as Numerical Rating Scale, Visual Analog Scale that is used for postoperative pain assessment may be problematic in geriatric or critically ill patients with communication problems. A method capable of the assessment of pain in objective manner has been searched for years. Analgesia nociception index, which is based on electrocardiographic data reflecting parasympathetic activity, has been proposed for this. In this study we aimed to investigate the effectiveness of analgesia nociception index as a tool for acute postoperative pain assessment. Our hypothesis was that analgesia nociception index may have good correlation with Numerical Rating Scale values. Methods A total of 120 patients of American Society of Anesthesiologists (ASA) physical status I and II undergoing any surgical procedure under halogenated-based anesthesia with fentanyl or remifentanil were enrolled for the study. At the 15th minute of arrival to the Postoperative Care Unit the patients' pain was rated on a 0-10 point Numerical Rating Scale. The patients' heart rate, blood pressure, and analgesia nociception index scores were simultaneously measured at that time. The correlation between analgesia nociception index, heart rate, blood pressure and Numerical Rating Scale was examined. Results The study was completed with 107 patients, of which 46 were males (43%). Mean (SD) analgesia nociception index values were significantly higher in patients with initial Numerical Rating Scale ≤3, compared with Numerical Rating Scale >3 (69.1 [13.4] vs. 58.1 [12.9] respectively, p < 0.001). A significant negative linear relationship (r 2 = -0.312, p = 0.001) was observed between analgesia nociception index and Numerical Rating Scale. Conclusion Analgesia nociception index measurements at postoperative period after volatile agent and opioid-based anesthesia correlate well with subjective Numerical Rating Scale scores.

Resumo Justificativa e objetivo As escalas baseadas na autoavaliação de pacientes, como a Escala Visual Numérica e a Escala Visual Analógica, que são usadas para avaliar a dor pós-operatória podem ser problemáticas em pacientes geriátricos ou em estado crítico com problemas de comunicação. Portanto, um método capaz de avaliar a dor de maneira objetiva vem sendo pesquisado há anos. O índice de analgesia/nocicepção, baseado em dados eletrocardiográficos que refletem a atividade parassimpática, tem sido proposto para tal avaliação. Neste estudo, objetivamos investigar a eficácia do índice de analgesia/nocicepção como uma ferramenta para a avaliação da dor pós-operatória aguda. Nossa hipótese foi que o índice de analgesia/nocicepção pode ter boa correlação com os valores da Escala de Classificação Numérica. Métodos Um total de 120 pacientes com estado físico ASA I e II, submetidos a qualquer procedimento cirúrgico com o uso de anestésicos halogenados associados a fentanil ou remifentanil, foi incluído no estudo. No 15º minuto após a chegada à sala de recuperação pós-anestesia, a dor dos pacientes foi avaliada em uma escala numérica de 0-10 pontos. Os escores de frequência cardíaca, pressão arterial e o índice de analgesia/nocicepção dos pacientes foram medidos simultaneamente naquele momento. A correlação entre o índice de analgesia/nocicepção, frequência cardíaca, pressão arterial e a Escala Visual Numérica foi avaliada. Resultados O estudo foi concluído com 107 pacientes, dos quais 46 eram do sexo masculino (43%). Os valores da média (DP) do índice de analgesia/nocicepção foram significativamente maiores nos pacientes com valor inicial na Escala Visual Numérica ≤ 3, em comparação com valor na mesma escala > 3 (69,1 [13,4] vs. 58,1 [12,9], respectivamente, p < 0,001). Uma relação linear negativa significativa (r2 = -0,312, p = 0,001) foi observada entre o índice de analgesia/nocicepção e a Escala Visual Numérica. Conclusão As mensurações do índice de analgesia/nocicepção no pós-operatório após anestesia com agentes halogenados e opioides mostraram boa correlação com os escores subjetivos da Escala Visual Numérica.