Uso de anestésicos tópicos para procedimientos timpánicos: revisión de la literatura / Use of topical anesthetics for tympanic procedures: a literature review

Los procedimientos intratimpánicos se realizan frecuentemente de manera ambulatoria en los policlínicos de otorrinolaringología. Dada la inervación de la membrana timpánica, estos procedimientos generan disconfort y dolor, por lo que la aplicación previa de anestésicos tópicos sobre la membrana timpánica y el conducto auditivo externo es habitual. Pese a su uso, no hay evidencia clara sobre la efectividad de estos y el correcto modo de aplicación. Se realizó una revisión de la literatura sobre la aplicación y uso de anestésicos tópicos previo a procedimientos intratimpánicos, donde pudimos concluir que actualmente no hay un estándar de oro para prevenir el dolor en los pacientes sometidos a procedimientos intratimpánicos, ya que en la mayoría de los estudios no se logró diferencia significativa entre el uso de anestésicos tópicos v/s placebo, al comparar dolor a los 5 y 45 minutos post procedimiento.

A literature review was performed to assess the use and efficacy of topical anesthetics in intratympanic procedures. The analysis led to the conclusion that a gold standard for pain prevention procedures is still lacking, as the majority of studies revised did not show statically significant differences between the use of topic anesthetics and placebo when compared pain at 5 and 45 minutes after procedures.

Usos y vías de administración de la lidocaína en oftalmología / Uses and Ways of Administering Lidocaine in Ophthalmology

La lidocaína es el anestésico local más utilizado a nivel mundial para la cirugía de catarata. También se usa de manera común en otras intervenciones quirúrgicas oftalmológicas del segmento anterior, la superficie del globo ocular, los párpados y vías lagrimales, así como en el segmento posterior del ojo. Esta revisión pretende brindar una actualización sobre las principales características, los efectos y vías de administración de la lidocaína usada en la oftalmología. Se realizó una búsqueda sistemática sobre el tema en publicaciones científicas indexadas en bases de datos, cuya información recopilada se resumió en este trabajo. La lidocaína se presenta en múltiples formas farmacéuticas, con variedad en concentración y formulación. Por lo general, para inyección se usan las concentraciones al 0,5 por ciento, 1 por ciento y 2 por ciento, para anestesia tópica en gel al 2 por ciento y en solución oftálmica al 4 por ciento. Su efecto como anestésico local es bien conocido, a nivel ocular se puede conseguir a través de inyecciones perioculares e intraoculares o mediante su aplicación tópica. Este efecto anestésico de la lidocaína ofrece cierta capacidad de dilatación pupilar, el cual se ha estudiado y aprovechado con frecuencia en los últimos años. Hoy día se encuentran en estudio otros efectos de la lidocaína a nivel local y sistémico. Los usos de la lidocaína en la oftalmología actual, están respaldados fundamentalmente por su eficacia y seguridad comprobadas en el tiempo(AU)

Lidocaine is the most widely used local anesthetic worldwide for cataract surgery. It is also commonly used in other ophthalmic surgical procedures of the anterior segment, surface of the eyeball, eyelids and lacrimal ducts, as well as in the posterior segment of the eye. This review aims to provide an update on the main characteristics, effects and ways of administering lidocaine used in ophthalmology. A systematic search on the subject was carried out in scientific publications indexed in databases, the information collected was summarized in this work. Lidocaine comes in multiple pharmaceutical forms, with a variety of concentrations and formulations. Generally, 0.5 percent, 1 percent and 2 percent concentrations are used for injection, 2 percent for topical anesthesia in gel and 4% in ophthalmic solution. Its effect as a local anesthetic is well known, at ocular level it can be achieved through periocular and intraocular injections or by topical application. This anesthetic effect of lidocaine offers some pupillary dilation capacity, which has been frequently studied and exploited in recent years. Other local and systemic effects of lidocaine are currently under study. The uses of lidocaine in ophthalmology today are supported primarily by its time-tested efficacy and safety(AU)

Cambios Hemodinámicos Asociados a Exodoncias de Terceros Molares Inferiores con el Uso de Articaína 4 % y/o Lidocaína 2 %: Una revisión sistemática / Hemodynamic Changes Associated with Lower Third Molar Extractions with the Use of Articaine 4 % and/or Lidocaine 2 %: A systematic Review

La exodoncia de los terceros molares inferiores es uno de los procedimientos clínicos más comunes en el cual el control del dolor mediante el bloqueo anestésico del nervio alveolar inferior, bucal y lingual resulta ser fundament al y la manera más común de hacerlo es mediante la infiltración de soluciones de anestesia local. Entre ellos la lidocaína y articaína son algunos de los más comunes y pueden estar asociado a vasoconstrictores como la epinefrina que puede provocar aumento de la presión arterial y frecuencia cardíaca razón por la cual se hace necesario la monitorización de cambios hemodinámicos durante la cirugía. Describir los cambios hemodinámicos asociados al uso de lidocaína al 2 % y/ o articaína al 4 % en la presión sistólica y diastólica, frecuencia cardiaca y saturación parcial de oxígeno en relación a distintos tiempos operatorios. Se realizó una revisión sistemática en las bases de datos de PubMed, SCOPUS, Web of Science y Sciencedirect. Se analizaron 7 ensayos clínicos controlados en los que utilizaron articaína al 4 % y/o lidocaína al 2 % con epinefrina al 1:100,000 y/o 1:200,000 en volúmenes de 1,8 a 5,4 mL, en los cuales evaluaron la presión sistólica y diastólica, frecuencia cardiaca y saturación parcial de oxígeno en distintos tiempos de la cirugía. Si bien hubo cambios en PAS, PAD, FC y SPO2, todas se mantuvieron dentro de rangos normales bajo el uso de articaína al 4 % y lidocaína al 2 % con epinefrina 1:100,000 y/o 1:200,000 a volúmenes de 1,8 a 5,4mL medidas a distintos tiempos operatorios.

The extraction of lower third molars is one of the most common clinical procedures in which pain control through anesthetic blockade of the lower alveolar, buccal and lingual nerves turns out to be essential and the most common way to do it is through the infiltration of solutions of local anesthesia. Among them, lidocaine and articaine are some of the most common and may be associated with vasoconstrictors such as epinephrine, which can cause an increase in blood pressure and heart rate, which is why it is necessary to monitor hemodynamic changes during surgery. To describe the hemodynamic changes associated with the use of 2 % lidocaine and/or 4 % articaine in systolic and diastolic pressure, heart rate and partial oxygen saturation in relation to different operative times. A systematic review was carried out in the PubMed, SCOPUS, Web of Science and Sciencedirect databases. Seven controlled clinical trials were analyzed in which 4 % articaine and/or 2 % lidocaine were used with epinephrine at 1:100,000 and/or 1:200,000 in volumes of 1,8 to 5,4 mL, in which systolic pressure was evaluated. and diastolic, heart rate and partial oxygen saturation at different times of surgery. Although there were changes in SBP, DBP, HR and SPO2, all remained within normal ranges under the use of 4 % articaine and 2 % lidocaine with epinephrine 1:100,000 and/or 1:200,000 at volumes of 1,8 to 5 .4mL measured at different operative times.

Local Anaesthetics Combined with Vasoconstrictors in Controlled Hypertensive Patients Undergoing Dental Procedures: Systematic Review and Meta-Analysis / Uso de Anestésicos Locales con Vasoconstrictor en Pacientes con Hipertensión Controlada Durante la Atención Odontológica: Una Revisión Sistemática y Metaanálisis

The aim of this systematic review is to assess the safety of local anaesthetics (LA) combined with vasoconstrictors (VC) for patients with controlled hypertension undergoing dental procedures. A comprehensive search strategy were used to identify all relevant randomized controlled trials (RCTs) that evaluated the effect of LA combined with VC. All searches covered the period from 1990 to February 2021. We performed a meta-analysis using random-effect models and assessed overall certainty in evidence using GRADE approach. Our search strategy yielded 1262 references. Finally, seven randomised trials were included, but only three were included in the meta-analysis. The use of LA with VC may result in little to no difference in the heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP), but the certainty of the evidence was assessed as low. Death, stroke, acute myocardial infarction, need for hospitalization, pain and bleeding were not reported by the included studies. The hemodynamic changes using VC do not imply an increased risk of occurrence of adverse cardiovascular events. The use of VC could even be recommendable considering their multiple advantages.

El objetivo de esta revisión sistemática es evaluar la seguridad del uso de anestésicos locales (AL) combinados con vasoconstrictor (VC) en pacientes con hipertensión controlada durante procedimientos dentales. Se realizó una estrategia de búsqueda para identificar todos los estudios clínicos aleatorizados (ECA) relevantes que evaluaban el efecto del AL combinado con VC. Todos los estudios fueron del periodo entre 1990 a febrero del 2021. Se realizó un meta-análisis usando modelos de efecto aleatorizado y una revisión de la certeza de la evidencia usando el método GRADE. Nuestra estrategia de búsqueda arrojó 1262 referencias. Finalmente, siete estudios clínicos aleatorizados fueron incluidos, de los cuales tres fueron incluidos en el meta-análisis. El uso de AL con VC produce una pequeña a ninguna diferencia en el pulso cardiaco, presión sistólica y diastólica, pero la certeza de la evidencia fue baja. Muerte, infarto agudo al miocardio, accidente cerebrovascular, necesidad de hospitalización, dolor y hemorragia no fueron reportados en los estudios incluidos. Los cambios hemodinámicos en el uso de VC no implican un aumento de riesgo de ocurrencia de efectos adversos cardiovasculares. El uso de VC puede ser recomendable considerando sus múltiples ventajas.

Caso clínico: Notalgia parestésica / Case report: Notalgia Paresthetica

Notalgia paresthetica (NP) is an under-diagnosed condition characterized by the presence of neuropathic pain associated with itching, in most cases localized at the dermatomes corresponding to the dorsal column of T2-T6; these symptoms are associated with the presence of skin lesions described as hyperpigmented macules in the affected areas. The etiology is multifactorial and multiple theories have been described, among them, the compromise of the cutaneous endings coming from the posterior branch of the nerve roots from T2 to T6. Different approaches are mentioned in the literature as treatment for NP, including systemic pharmacological management with neuromodulators, topical management with local anesthetics and capsaicin, and interventional analgesic strategies, among others. We present the case of a patient with NP who received multimodal pharmacological management with a favorable response.

La notalgia parestésica (NP) es una condición poco diagnosticada que se caracteriza por la presencia de dolor de componente neuropático y prurito, se localiza a nivel de los dermatomas correspondientes a la columna dorsal de T2-T6 en la mayoría de los casos; dichos síntomas se asocian a la presencia de lesiones en piel descritas como máculas hiperpigmentadas en los sitios afectados. Su etiología es multifactorial y se han descrito múltiples teorías, dentro de ellas se destaca el compromiso de las terminaciones cutáneas provenientes de la rama posterior de las raíces nerviosas de T2 a T6. Como tratamiento de la NP se menciona en la literatura diferentes abordajes incluyendo el manejo farmacológico sistémico con neuromoduladores, tópico con anestésicos locales y capsaicina y tratamiento analgésico intervencionista entre otros. Se presenta el caso de un paciente con NP que ha recibido manejo farmacológico multimodal con una respuesta favorable.

Ultrasound-Guided Continuous Thoracic Paravertebral Block Improves Patient's Quality of Recovery After Open Hepatectomy: A Randomized, Double-Blind, Placebo-Controlled Trial / 中国医学科学杂志(英文版)

Background Ultrasound-guided continuous thoracic paravertebral block can provide pain-relieving and opioid-sparing effects in patients receiving open hepatectomy. We hypothesize that these effects may improve the quality of recovery (QoR) after open hepatectomy. Methods Seventy-six patients undergoing open hepatectomy were randomized to receive a continuous thoracic paravertebral block with ropivacaine (CTPVB group) or normal saline (control group). All patients received patient-controlled intravenous analgesia with morphine postoperatively for 48 hours. The primary outcome was the global Chinese 15-item Quality of Recovery score on postoperative day 7, which was statistically analyzed using Student's t-test. Results Thirty-six patients in the CTPVB group and 37 in the control group completed the study. Compared to the control group, the CTPVB group had significantly increased global Chinese 15-item Quality of Recovery scores (133.14 ± 12.97 vs. 122.62 ± 14.89, P = 0.002) on postoperative day 7. Postoperative pain scores and cumulative morphine consumption were significantly lower for up to 8 and 48 hours (P < 0.05; P = 0.002), respectively, in the CTPVB group. Conclusion Perioperative CTPVB markably promotes patient's QoR after open hepatectomy with a profound analgesic effect in the early postoperative period.

Analgesic effect of ropivacaine after arthroscopic reconstruction of the ligament in athletes / Efeito analgésico da ropivacaína após reconstrução artroscópica do ligamento em atletas / El efecto de la ropivacaína en el dolor después de la reconstrucción artroscópica de ligamentos de un atleta

ABSTRACT After arthroscopic ligament reconstruction, athletes still need to go through a postoperative rehabilitation training period and suffer the possible pain that can go from moderate to severe. Commonly used analgesic medications, ropivacaine and fentanyl have the effect of relieving athletes' pain. To study the analgesic effect of ropivacaine on arthroscopic reconstruction of the knee ligament, the steps of reconstruction and pharmacology of ropivacaine were first introduced. Next, the analgesic effects of ropivacaine and fentanyl in 86 athletes were compared on muscle strength recovery, patient satisfaction, and pain score. The results showed that the satisfaction of patients with ropivacaine was 95.35%, and the incidence of postoperative adverse reactions was only 9.30%. These results indicate that ropivacaine has a better analgesic effect in arthroscopic reconstruction of the knee ligament in athletes, which is suitable for postoperative rehabilitation.

RESUMO Após a reconstrução artroscópica do ligamento, os atletas ainda precisam passar por um longo período de treinamento pós-operatório de reabilitação e suportar a possível dor de moderada a severa. Os medicamentos analgésicos ropivacaina e fentanilo comumente utilizados têm o efeito de aliviar a dor dos atletas. Para estudar o efeito analgésico da ropivacaína na reconstrução artroscópica do ligamento do joelho foram introduzidos, em primeiro lugar, os passos da reconstrução artroscópica do ligamento e os da farmacologia da ropivacaína. Em seguida, os efeitos analgésicos da ropivacaína e o fentanilo em 86 atletas foram comparados com a recuperação na força muscular, na satisfação do paciente e na pontuação da dor. Os resultados mostraram que a satisfação dos doentes com a ropivacaína chegava a 95.35%, e a incidência de reações adversas pós-operatórias foi apenas de 9.30%. Estes resultados indicam que a ropivacaína tem melhor efeito analgésico na reconstrução artroscópica do ligamento do joelho, o que é adequado para a reabilitação pós-operatória.

RESUMEN Después de la reconstrucción artroscópica del ligamento, los atletas aun precisan pasar por un largo período de entrenamiento posoperatorio de rehabilitación y soportar el posible dolor que puede ir de moderado a severo. Los medicamentos analgésicos, ropivacaína y fentanilo que son comúnmente utilizados, tienen el efecto de aliviar el dolor de los atletas. Para estudiar el efecto analgésico de la ropivacaína en la reconstrucción artroscópica del ligamento de la rodilla fueron introducidos, en primer lugar, los pasos de la reconstrucción y de la farmacología de la ropivacaína. Enseguida, los efectos analgésicos de la ropivacaína y el fentanilo en 86 atletas fueron comparados en la recuperación de la fuerza muscular, en la satisfacción del paciente y en la puntuación del dolor. Los resultados mostraron que la satisfacción de los pacientes con la ropivacaína llegaba a 95.35%, y la incidencia de reacciones adversas posoperatorias fue apenas de 9.30%. Estos resultados indican que la ropivacaína tiene mejor efecto analgésico en la reconstrucción artroscópica del ligamento de la rodilla de los atletas, lo que es adecuado para la rehabilitación posoperatoria.

Comparación del bloqueo periprostático con lidocaina y supositorio de diclofenac y placebo en la biopsia prostática / Comparison of periprostatic block with lidocaine and diclofenac suppository and placebo in prostate biopsy

El bloqueo del nervio peri prostático con lidocaína, proporciona un buen alivio del dolor en la realización de la biopsia prostática guiada por ultrasonido, pero el dolor post-procedimiento, puede llegar a ser significativo, la adición del supositorio de diclofenac, podría proporcionar alivio adicional. Se asignaron al azar pacientes en 2 grupos el grupo 1 bloqueo con lidocaína del plexo peri prostático + supositorio de diclofenac sódico y el grupo 2 bloqueo con lidocaína del plexo peri prostático + supositorio de placebo, realizando biopsia doble sextante, el dolor a varios intervalos después del procedimiento se registró en una escala visual análoga (EVA) de 0 a 10. Los 2 grupos fueron similares en cuanto a edad, volumen de próstata, antígeno prostático específico, diagnóstico histopatológico. Los pacientes que recibieron diclofenac tuvieron puntajes de dolor significativamente más bajos que los que recibieron placebo (2 frente a 3,35) p 0,02. La administración rectal de diclofenac antes de la realización de la biopsia de próstata es un procedimiento simple que alivia significativamente el dolor experimentado sin aumento en la morbilidad(AU)

The peri-prostatic nerve block with lidocaine, provides good pain relief in performing ultrasoundguided prostate biopsy, but the postprocedure pain can be significant, the addition of diclofenac suppository, could provide additional relief. Patients were randomly assigned in 2 groups to group 1 blockade with lidocaine of the prostatic peri plexus + suppository of diclofenac sodium and group 2 blockade with lidocaine of the prostatic peri plexus + placebo suppository, performing double sextant biopsy, pain at several intervals after the procedure was recorded on a visual analog scale (EVA) from 0 to 10. Thee 2 groups were similar in terms of age, prostate volume, prostate-specific antigen, histopathological diagnosis. Patients who received diclofenac had pain scores significantly lower than those who received placebo (2 vs. 3.35) p 0.02. Rectal administration of diclofenac before performing a prostate biopsy is a simple procedure that relieves significantly pain experienced without increased morbidity(AU)

Continuous peripheral nerve block for in-patients with lower limb ischemic pain

OBJECTIVES: Demonstrate that continuous peripheral nerve block (CPNB) may be an alternative with adequate analgesia and a lower incidence of side effects for ischemic pain due peripheral obstructive arterial disease (POAD). METHODS: Retrospective cohort study with 21 patients with POAD, Fontaine IV graded, with foot pain. Patients were submitted to continuous sciatic nerve block (CSNB), through a perineural catheter. Primary outcomes were pain intensity (by numerical rating scale) and opioid consumption (in oral morphine equivalents). RESULTS: During CSNB, pain scores markedly decreased in comparison to the pre-block period. CONCLUSIONS: CPNB may be a good option for ischemic pain treatment in in-patients, as it provides effective pain control with fewer adverse effects.

Perfil de utilização de anestésicos locais de uma cidade brasileira com ênfase em diabéticos / Profile of use of local anesthetics in a Brazilian city with emphasis on diabetics

Objetivo: avaliar o conhecimento de cirurgiões-dentistas que trabalham em consultórios particulares de Palmas, Tocantins, quanto à utilização de anestésicos locais em pacientes portadores de diabetes mellitus. Materiais e método: trata-se de um estudo descritivo qualitativo, aprovado pelo Comitê de Ética em Pesquisa da FAMERP de São José do Rio Preto, sob o protocolo 032/2007 e CAAE: 0065.0.000.140-07, respeitando-se a Resolução 466/12, do Conselho Nacional de Saúde. A coleta de dados foi realizada por meio da aplicação de um questionário, utilizando um formulário estruturado. Resultados: de 113 participantes, 47 (41,6%) eram do sexo masculino e 66 (58,4%) do sexo feminino, com idade média de 35 anos. O anestésico mais utilizado pelos cirurgiões-dentistas avaliados foi a lidocaína 2% + adrenalina 1:100.000 (53,1%), o qual também é o mais utilizado para pacientes diabéticos controlados (64,6%). Quanto à variedade de anestésicos, 47,8% dos avaliados relataram possuir somente 3 tipos de anestésicos no consultório e que 83,2% nunca presenciaram nenhum problema decorrente do uso de anestésico. Além disso, 65,5% relataram não participar de cursos para atualização de conhecimentos, sendo que 53,1% mostraram-se insatisfeitos com o ensino de anestesiologia que receberam na graduação. Conclusão: observou-se que os cirurgiões-dentistas do atendimento odontológico particular de Palmas precisam de uma reciclagem profissional, a fim de atualizarem conhecimentos adquiridos na graduação sobre indicação e utilização de anestésicos locais em tratamentos odontológicos de pacientes com necessidades especiais, com ênfase em pacientes portadores de diabetes mellitus.(AU)

Objective: to evaluate the knowledge of dentists who work in private offices in Palmas, Tocantins, regarding the use of local anesthetics in patients with diabetes mellitus. Materials and method: this research is a qualitative descriptive study, approved by the Research Ethics Committee of FAMERP from São José do Rio Preto, under protocol number 032/2007 and CAAE: 0065.0.000.140-07 in compliance with the Resolution 466/12 of the National Health Council. Data collection was performed through the application of a questionnaire, using a structured form. Results: 47 (41.6%) out of 113 participants were male and 66 (58.4%) female, with an average age of 35 years old. The anesthetic most used by the dentists evaluated was lidocaine 2% + adrenaline 1: 100,000 (53.1%) which is also the most used for controlled diabetic patients (64.6%). As for the variety of anesthetics, 47.8% of those evaluated reported having only 3 types of anesthetics in the office and that 83.2% never saw any problems resulting from the use of anesthetics. Furthermore, 65.5% reported not participating in courses to update knowledge and 53.1% were dissatisfied with the teaching of anesthesiology they received during graduation. Conclusion: it was observed that dentists who work in private dental offices in Palmas need a professional retraining in order to update knowledge acquired during graduation on the indication and use of local anesthetics in dental treatments for patients with special needs, with an emphasis on patients with diabetes mellitus.(AU)

Anestesia espinal con meperidina en paciente con hipersensibilidad a anestésicos locales / Spinal cord anesthesia with meperidine in a patient with hypersensitivity to local anesthesia

Introducción: La meperidina (o petidina) es un opioide sintético que tiene propiedades anestésicas locales bien conocidas, y ha sido utilizada por vía intratecal en cirugía general, urológica y obstétrica de forma segura. Este puede ser usado en anestesia espinal en paciente con hipersensibilidad a los anestésicos locales. Objetivo: Describir el manejo anestésico en una paciente con hipersensibilidad a los anestésicos locales con uso de meperidina intratecal. Presentación del caso: Se presenta una paciente femenina de 54 años de edad con historia previa de hipersensibilidad a los anestésicos locales, programada para colporrafia anterior, a la cual se le realiza una técnica regional, administrando meperidina intratecal. Para la analgesia posoperatoria se suministró diclofenaco de sodio en dosis única de 75 mg, por vía IV previo a la incisión. Conclusiones: Con la técnica descrita se logra un bloqueo sensitivo y motor adecuado, estabilidad de los signos vitales intraoperatoria y recuperación óptima en el posoperatorio inmediato. Es una alternativa más en el manejo de los pacientes con hipersensibilidad a los anestésicos locales(AU)

Introduction: Meperidine (or pethidine) is a synthetic opioid with well-known local anesthetic properties. It has been safely used intrathecally in general, urological and obstetric surgery. This can be used in spinal anesthesia in patients with hypersensitivity to local anesthetics. Objective: To describe anesthetic management of a patient with hypersensitivity to local anesthetics with the use of intrathecal meperidine. Case presentation: The case is presented of a 54-year-old female patient with a previous history of hypersensitivity to local anesthetics, scheduled for anterior colporrhaphy, who is performed regional technique, administering intrathecal meperidine. For post-operative analgesia, diclofenac sodium was administered intravenously in a single dose of 75 mg before the incision. Conclusions: The described technique allowed to achieve adequate sensory and motor block, stability of intraoperative vital signs, and optimal recovery in the immediate postoperative period. It is another alternative in the management of patients with hypersensitivity to local anesthetics(AU)

Eficacia analgésica del EMLA en procedimientos transcutáneos. Revisión sistemática / Analgesic efficacy of EMLA in transcutaneous procedures. Systematic review

Los parches de EMLA son frecuentemente utilizados como anestésicos locales durante la realización en procedimientos invasivos. Con el fin de valorar su eficacia y compararla con la de otros analgésicos y anestésicos disponibles, se realizó una revisión sistemática de todos los estudios realizados que cumplieran criterios de inclusión entre los años 1990 y 2019. Población y métodos: la búsqueda bibliográfica de la evidencia disponible fue realizada en las bases de datos de Cochrane Medline y Lilacs. Se incluyeron todos los ECA y revisiones sistemáticas en pacientes menores de 16 años entre los años 1990 y 2019. Resultados: Fueron hallados 31 artículos de los cuales 21 cumplían con los criterios de inclusión. De dichos 21, solamente 8 estudios resultaron de muy buena y excelente calidad metodológica (JADAD). Conclusiones: El EMLA demostró mayor eficacia como analgésico en el 100% de los estudios donde se comparaba respecto del placebo. Sin embargo, no se encontraron diferencias significativas respecto de otros analgésicos farmacológicos y no farmacológicos.(AU)

EMLA patches are commonly used as local anesthetics in minor invasive procedures. To assess efficacy and compare the patches with other available analgesics and anesthetics, a systematic review was conducted evaluated all studies that met the inclusion criteria published between 1990 and 2019. Population and methods: A literature search of the available evidence was conducted in the Cochrane, Medline, and Lilacs databases. All RCTs and systematic reviews in patients younger than 16 years published between 1990 and 2019 were included. Results: 31 articles were identified of which 21 met the inclusion criteria. Of these 21, of only 8 studies the methodology was of very good and excellent quality (JADAD). Conclusions: EMLA better efficacy as an analgesic in 100% of the studies comparing EMLA patches with placebo. However, no significant differences were found when comparing the patches with other pharmacological and non-pharmacological analgesics.(AU)

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.

Pain management strategies in penile implantation / 亚洲男科学杂志(英文版)

The opioid epidemic continues to be a serious public health concern. Many have pointed to prescription drug misuse as a nidus for patients to become addicted to opioids and as such, urologists and other surgical subspecialists must critically define optimal pain management for the various procedures performed within their respective disciplines. Controlling pain following penile prosthesis implantation remains a unique challenge for urologists, given the increased pain patients commonly experience in the postoperative setting. Although most of the existing urological literature focuses on interventions performed in the operating room, there are many studies that examine the role of preoperative adjunctive pain medicine in diminishing postoperative narcotic requirements. There are relatively few studies looking at postoperative strategies for managing pain in prosthetic surgery with follow-up past the immediate hospitalization. This review assess the various strategies employed for managing pain following penile implantation through the lens of the current state of the opioid crisis, thus examining how urologists can responsibly treat pain without contributing to the growing threat of opioid addiction.

Eficacia del bloqueo poplíteo por vía lateral / Effectiveness of the blockade popliteal for via lateral

Introducción: Los bloqueos nerviosos periféricos son un componente aceptado en la práctica médica desde el área quirúrgica, el control del dolor crónico y el posoperatorio. Objetivo: Evaluar la eficacia del bloqueo poplíteo por vía lateral en los pacientes intervenidos por afecciones en el pie y tobillo. Métodos: Se realizó un estudio analítico transversal en los pacientes intervenidos por afecciones en el pie y tobillo en el período de septiembre 2015 a septiembre 2018. Se constituyó el universo con 431 pacientes y la muestra por 209. Resultados: Más de las tres cuartas partes de los pacientes intervenidos por afecciones del pie y del tobillo a los que se les aplica el bloqueo se encuentran por encima de la quinta década de la vida. La mayor parte de ellos corresponden al rango de 51 Kg a los 70 Kg, con cuatro a seis cm de profundidad de la aguja para la localización del nervio basado en la ecuación de la recta. Es 19 veces más probable en ellos la ausencia de dolor en las primeras seis horas del posoperatorio después del bloqueo y más probable el éxito de la técnica propuesta con la determinación de la profundidad en cm de la aguja basado en la ecuación de la recta, con odds ratio de 31. Conclusiones: Se evaluó de eficaz el bloqueo poplíteo por vía lateral en la mayor parte de pacientes intervenidos por afecciones en el pie y tobillo(AU)

Background: the blockades nervous peripherals are a component accepted in the medical practice, from the surgical area, control of the chronic pain and postoperatory. Objective: to evaluate the effectiveness of the blockade popliteal for via lateral in the patients intervened by affections in the foot and ankle. Methods: it was carried out a study transversal analytic of patients intervened by affections in the foot and ankle in the period from September 2015 to September 2018. The universe was constituted with 431 patients and the sample by 209. Results: more than the fourth three parts of the patients intervened by affections of the foot and of the ankle to those that are applied the blockade popliteal for via lateral they are above the fifth decade of the life. Most of the patients belong together to the range from 51 to the 70 Kgs with four to six cm of depth based on the equation of the straight line. It is more probable 19 times in the patients the pain absence in the first six hours of the post operatory after the blockade and more probable the success of the technique proposal with the determination of the depth in cm of the needle based before on the equation of the straight line described with odds ratio of 31. Conclusions: the evaluation of the effectiveness of the blockade popliteal for via lateral increases the anesthesiologist's therapeutic arsenal and it redounds in benefits for the patient during the perioperatorio, the application of this technique in appropriate clinical situations adds alternative valuable to the anesthetic attendance(AU)

Fascitis plantar. Criterios y experiencias sobre la infiltración con anestésicos locales y corticoesteroides / Plantar fasciitis Criteria and experiences on infiltration with local anesthetics and corticosteroids

Introducción: Dentro del grupo de las enfermedades del sistema osteomioarticular la fascitis plantar (FP) es una de las causas más frecuente de dolor crónico del pie. Objetivo: aportar criterios sobre el empleo de la infiltración de anestésicos locales y corticoesteroides para el tratamiento de la fascitis plantar. Desarrollo: se seleccionaron las infiltraciones de corticoesteroides y de anestésicos locales que se realizan con mayor frecuencia en la práctica clínica, se analizó su efectividad según la evidencia en la literatura internacional y a partir de ahí se contrastaron los resultados encontrados con los criterios y experiencias de los autores de este trabajo. Conclusiones: Las consideraciones realizadas en este estudio apuntan a que el uso de los corticoides mediante infiltraciones en patologías ortopédicas es un medio valioso para mejorar la inflamación de los tejidos y para el alivio de los dolores, tanto cuando se emplea en las articulaciones como en las partes blandas(AU)

Introduction: within the group of diseases of the osteomioarticular system, plantar fasciitis (FP) is one of the most frequent causes of chronic foot pain. Objective: to provide criteria on the use of infiltration of local anesthetics and corticosteroids for the treatment of plantar fasciitis. Development: the infiltrations of corticosteroids and local anesthetics that are performed more frequently in clinical practice were selected, their effectiveness was analyzed according to the evidence in the international literature and from there the results were contrasted with the criteria and experiences of the patients authors of this work. Conclusions: the considerations made in this study suggest that the use of corticosteroids through infiltrations in orthopedic pathologies is a valuable means to improve inflammation of the tissues and for the relief of pain, both when used in the joints and in the joints and soft parts(AU)

Posterior quadratus lumborum block for primary total hip arthroplasty analgesia: a comparative study / Bloqueio anestésico do quadrado lombar posterior para analgesia na artroplastia total do quadril primária: estudo comparativo

ABSTRACT Objective To compare analgesia and opioid consumption for patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Methods The medical records of patients undergoing unilateral total hip arthroplasty between January 1st, 2017 and March 31, 2018 were reviewed, and 238 patients were included in the study. The primary outcome was postoperative opioid consumption in the first 24 postoperative hours. Secondary outcomes were intraoperative, post anesthesia care unit, and 48-hour opioid consumption, postoperative pain Visual Analog Scale scores, and post-anesthesia care unit length of stay. Primary and secondary endpoint data were compared between patients undergoing primary total hip arthroplasty with preoperative posterior quadratus lumborum block with patients who did not receive quadratus lumborum block. Results For the patients who received quadratus lumborum block, the 24-hour total oral morphine equivalent (milligram) requirements were lower (53.82mg±37.41), compared to the patients who did not receive quadratus lumborum block (77.59mL±58.42), with p=0.0011. Opioid requirements were consistently lower for the patients who received quadratus lumborum block at each additional assessment time point up to 48 hours. Pain Visual Analog Scale scores were lower up to 12 hours after surgery for the patients who received a posterior quadratus lumborum block, and the post-anesthesia care unit length of stay was shorter for the patients who received quadratus lumborum block. Conclusion Preoperative posterior quadratus lumborum block for primary total hip arthroplasty is associated with decreased opioid requirements up to 48 hours, decreased Visual Analog Scale pain scores up to 12 hours, and shorter post-anesthesia care unit length of stay. Level of evidence: III

RESUMO Objetivo Comparar a analgesia e o uso de opioides em pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e pacientes que não receberam o bloqueio do quadrado lombar. Métodos Revisamos os prontuários de pacientes submetidos à artroplastia total do quadril unilateral entre 1º de janeiro de 2017 e 31 de março de 2018, e 238 pacientes foram incluídos no estudo. O desfecho primário foi o consumo de opioides no pós-operatório nas primeiras 24 horas. Os desfechos secundários foram consumo de opioide no intraoperatório, na sala de recuperação pós-anestésica e nas primeiras 48 horas, escores de Escala Visual Analógica de dor pós-operatória, e tempo de permanência na recuperação pós-anestésica. Os desfechos primário e secundários foram comparados entre os pacientes submetidos à artroplastia total do quadril primária com bloqueio pré-operatório do quadrado lombar posterior e aqueles que não receberam o bloqueio do quadrado lombar. Resultados Para o grupo que recebeu o bloqueio, as doses totais de morfina por via oral em 24 horas foram menores (53,82mg±37,41) em comparação ao grupo sem bloqueio (77,59mg±58,42), com p=0,0011. A utilização de opioides foi consistentemente menor para o grupo que recebeu o bloqueio em cada tempo adicional de avaliação até 48 horas. Os escores da Escala Visual Analógica até 12 horas após a cirurgia para os pacientes que receberam o bloqueio do quadrado lombar posterior e o tempo de permanência na sala de recuperação pós-anestésica foram menores para o grupo que recebeu o bloqueio. Conclusão O bloqueio anestésico do quadrado lombar posterior para artroplastia total do quadril primária está associado à diminuição do uso de opioides nas primeiras 48 horas, diminuição do escore de dor da Escala Visual Analógica em até 12 horas, e menor tempo de permanência na sala de recuperação pós-anestésica. Nível de evidência: III

The myofascial component of the pain in the painful shoulder of the hemiplegic patient

OBJECTIVES: Poststroke shoulder pain occurs very frequently and compromises function and quality of life. Because treatment depends on a multidisciplinary approach, it is desirable to optimize effectiveness. Myofascial pain syndrome is defined by the presence of trigger points that can also be found in spastic stroke patients. The aim of this study was to evaluate the frequency of myofascial pain in the shoulder girdle muscles in patients with poststroke shoulder pain and to document the clinical and functional results obtained with specific treatment for this condition. METHODS: Spastic stroke hemiplegic patients undergoing rehabilitation at the Rehabilitation Center of the Hospital das Clínicas of the Ribeirão Preto Medical School of the University of São Paulo were evaluated regarding the intensity and characteristics of shoulder pain, previous therapeutic interventions, shoulder goniometry and the presence of trigger points. Patients underwent trigger point blockade by intramuscular infiltration of 1% lidocaine. The evaluation and treatment procedures were repeated in the subsequent 3 weeks as long as the pain intensity was greater than 5 on a visual analog scale (VAS). In the fourth week, the evaluation procedures were repeated. Patients who were in a multiprofessional rehabilitation program were instructed to continue the treatment, and the others received complementary therapeutic advice if necessary to initiate it. The evaluations were performed at 0, 1, and 3 weeks and after 4 months. RESULTS: Twenty-one patients (13 men; age=67.8±10.2 years; right hemiparesis: 11) participated in the study, and there was a reduction in pain assessed by VAS from baseline (7.6±2.7) to the first week (5.8±3.6; p<0.05) through the end of the third week (5.2±3.5; p<0.05), but not at the end of four months (6.6±2.9; p=0.11). Good responders had significantly lower pain levels after the third week and presented with a larger range of motion for passive abduction by the end of 4 months. These results demonstrate that the myofascial component of pain should be considered in poststroke shoulder pain and that its treatment may be a pathway for the rapid and long-lasting relief of symptoms. CONCLUSION: Trigger point blockade with lidocaine can reduce pain perception in spastic hemiplegic shoulder in as much as 50% of stroke survivors for four months.

Gingivoestomatitis herpética aguda en paciente adulto / Acute herpetic gingivostomatitis in adult patients

Introduction: Herpetic gingivostomatitis is an infection caused by herpes simplex virus, which affects mainly children patients, being uncommon this manifestation in adults. It initially appears with prodromal signs and then local signs show up. The treatment for this disease is only supportive, because there is already a peak of viral replication when it was diagnosed. Objectives: To report a case of herpetic gingivostomatitis and to discuss its clinical characteristics and treatment. Case report: The patient looked for clinic care for presenting painful oral lesions with little time of evolution. With no medical history, the patient reported using antibiotics and antifungals. Oroscopy showed multiple coalescing ulcerative lesions affecting the gum tissue, tongue, lips and hard palate. It has been diagnosed clinically as herpetic gingivostomatitis and has been treated with supportive treatment (analgesics, topical anesthetic and chlorhexidine digluconate 0,12 percent). The patient returned after one week with improvement of the condition. Conclusion: The correct diagnosis, through the evident clinical manifestations, prevents the indiscriminate use of antibiotics, leading to better response of the patient(AU)

Introducción: La gingivoestomatitis herpética es una infección causada por el virus herpes simple, que afecta principalmente a los pacientes infantiles, la cual resulta inusual en adultos. Inicialmente surge con señales prodrómicas y solo después se presentan señales locales. El tratamiento para este cuadro es solo de soporte, pues cuando se diagnostica ya hay un pico de replicación viral. Objetivo: informar un caso de gingivoestomatitis herpética y discutir sus características clínicas y tratamiento. Presentación del caso: El paciente buscó atención clínica por presentar dolorosas lesiones bucales con poco tiempo de evolución. Sin historial médico, informó que estaba usando antibióticos y antifúngicos, sin remisión de la condición. En la oroscopia se observaron múltiples lesiones ulcerativas coalescentes que afectan el tejido de la gingiva, la lengua, los labios y el paladar duro. Se ha diagnosticado clínicamente como gingivoestomatitis herpética y se ha tratado con tratamiento de apoyo (analgésicos, anestésicos tópicos y digluconato de clorhexidina al 0,12 por ciento). El paciente regresó después de una semana con una mejoría de la condición. Conclusion es: El correcto diagnóstico, a través de las manifestaciones clínicas evidentes, previene el uso indiscriminado de antibióticos, lo que lleva a una mejor respuesta del paciente(AU)