Evaluation of early effectiveness of local infiltration anesthesia with compound betamethasone in total knee arthroplasty / 中国修复重建外科杂志

OBJECTIVE@#To evaluate the early effectiveness of local infiltration anesthesia (LIA) with compound betamethasone in total knee arthroplasty (TKA).@*METHODS@#The clinical data of 102 patients with knee osteoarthritis who were treated by TKA and met the selection criteria between May 2022 and March 2023 were retrospectively analyzed. They were divided into control group and study group according to whether LIA preparation was added with compound betamethasone, with 51 cases in each group. There was no significant difference of baseline data, such as age, gender, body mass index, operative side, preoperative range of motion (ROM), Knee Society Score (KSS), white blood cell (WBC), and hematocrit between the two groups ( P>0.05). The intraoperative total blood loss and hidden blood loss were recorded, and WBC was recorded on the 1st, 2nd, and 3rd days after operation. Pain was assessed by visual analogue scale (VAS) score on the 1st, 2nd, and 3rd days after operation and morphine intake milligrames equivalent within 48 hours after operation. Passive ROM, maximum extension and flexion angles of knee joint were measured on the 3rd day after operation; the early postoperative complications were recorded.@*RESULTS@#There was no significant difference in total blood loss and hidden blood loss between the two groups ( P>0.05). The postoperative pain levels in both groups were relatively mild, and there was no significant difference in VAS scores in the first 3 days after operation and in morphine intake milligrams equivalent within 48 hours after operation between the two groups ( P>0.05). The WBC in the first 3 days after operation was significantly improved in both groups ( P<0.05). The WBC in the study group was significantly higher than that in the control group on the 1st and 2nd days after operation ( P<0.05), but there was no significant difference between the two groups on the 3rd day after operation ( P>0.05). On the 3rd day after operation, the maximum extension angle of knee joint in the study group was smaller than that in the control group, while the maximum flexion angle and passive ROM of knee joint in the study group were larger than those in the control group, and the differences were significant ( P<0.05). There were 6 cases of fever and 17 cases of deep venous thrombosis in the control group, and 1 case and 14 cases in the study group, respectively. There was no poor wound healing and periprosthetic joint infection in the two groups, and there was no significant difference in the incidence of complications between the two groups ( P>0.05).@*CONCLUSION@#The application of compound betamethasone in LIA during TKA is a safe and optimal strategy to promote the early postoperative rehabilitation of patients.

Effect of magnesium sulfate with ketamine infusions on intraoperative and postoperative analgesia in cancer breast surgeries: a randomized double-blind trial

Abstract Background Opioids are the cornerstone in managing postoperative pain; however, they have many side effects. Ketamine and Magnesium (Mg) are NMDA receptor antagonists used as adjuvant analgesics to decrease postoperative opioid consumption. Objective We assumed that adding Mg to ketamine infusion can improve the intraoperative and postoperative analgesic efficacy of ketamine infusion alone in cancer breast surgeries. Methods Ninety patients aged between 18 and 65 years and undergoing elective cancer breast surgery were included in this prospective randomized, double-blind study. Group K received ketamine 0.5 mg.kg-1 bolus then 0.12 mg.kg-1.h-1 infusion for the first 24 hours postoperatively. Group KM: received ketamine 0.5 mg.kg-1 and Mg sulfate 50 mg.kg-1, then ketamine 0.12 mg.kg-1.h-1 and Mg sulfate 8 mg.kg-1.h-1 infusions for the first 24 hours postoperative. The primary outcome was the morphine consumption in the first 24 hours postoperative, while the secondary outcomes were: intraoperative fentanyl consumption, NRS, side effects, and chronic postoperative pain. Results Group KM had less postoperative opioid consumption (14.12 ± 5.11 mg) than Group K (19.43 ± 6.8 mg). Also, Group KM had less intraoperative fentanyl consumption. Both groups were similar in postoperative NRS scores, the incidence of side effects related to opioids, and chronic neuropathic pain. Conclusion Adding Mg to ketamine infusion can safely improve intraoperative and postoperative analgesia with opioid-sparing effect in cancer breast surgery.

Inkk Trial - Intraoperative ketamine for perioperative pain management following total knee endoprosthetic replacement in oncology: a double-blinded randomized trial

Abstract Background There has been a growing interest in the use of ketamine following orthopedic surgeries. We hypothesized that low dose intravenous ketamine during surgery would help in mobilization following total knee replacement (TKR) in oncology patients as assessed by the timed to up and go (TUG) test at 72 hours post-surgery. Our secondary objectives were to compare the opioid requirement at the end of 72 hours, pain scores, satisfaction with pain management, adverse effects, range of joint movement achieved in the post-operative period and the functional recovery at the end of 1 month. Methods After the ethics commitee approval, registration of the trial with the Clinical Trial Registry - India (CTRI), and informed consent, this double-blinded trial was conducted. Using computer generated randomization chart, an independent team randomized the patients into ketamine group which received at induction, a ketamine bolus dose of 0.5 mg.kg-1 before the incision followed by 10 µg.kg-1min-1 infusion which was maintained intraoperatively till skin closure and the saline group received an equivalent volume of saline. Postoperatively, patient controlled morphine pumps were attached and the pain score with morphine usage were recorded for 72 hours. The TUG tests and range of motion were assessed by the physiotherapists until 72 hours. Results Fifty-two patients were enrolled in the trial. Demographics were comparable. No significant intraoperative hemodynamic changes and post-operative adverse events were noted between the groups. A decrease in the TUG test, along with decreased opioid usage with a better range of movements was noted in the ketamine group, but this was not statistically significant. Day of discharge, patient satisfaction score, and functional recovery assessed by Oxford Knee Score (OKS) were comparable between the groups. Conclusion In conclusion, low dose intraoperative ketamine infusion does not provide clinical benefit in perioperative pain management and postoperative rehabilitation following total knee endoprosthetic replacement in oncology.

Blockade of the Dopamine D3 Receptor Attenuates Opioids-Induced Addictive Behaviours Associated with Inhibiting the Mesolimbic Dopamine System / 神经科学通报·英文版

Opioid use disorder (OUD) has become a considerable global public health challenge; however, potential medications for the management of OUD that are effective, safe, and nonaddictive are not available. Accumulating preclinical evidence indicates that antagonists of the dopamine D3 receptor (D3R) have effects on addiction in different animal models. We have previously reported that YQA14, a D3R antagonist, exhibits very high affinity and selectivity for D3Rs over D2Rs, and is able to inhibit cocaine- or methamphetamine-induced reinforcement and reinstatement in self-administration tests. In the present study, our results illustrated that YQA14 dose-dependently reduced infusions under the fixed-ratio 2 procedure and lowered the breakpoint under the progressive-ratio procedure in heroin self-administered rats, also attenuated heroin-induced reinstatement of drug-seeking behavior. On the other hand, YQA14 not only reduced morphine-induced expression of conditioned place preference but also facilitated the extinguishing process in mice. Moreover, we elucidated that YQA14 attenuated opioid-induced reward or reinforcement mainly by inhibiting morphine-induced up-regulation of dopaminergic neuron activity in the ventral tegmental area and decreasing dopamine release in the nucleus accumbens with a fiber photometry recording system. These findings suggest that D3R might play a very important role in opioid addiction, and YQA14 may have pharmacotherapeutic potential in attenuating opioid-induced addictive behaviors dependent on the dopamine system.

Targeting Peripheral μ-opioid Receptors or μ-opioid Receptor-Expressing Neurons Does not Prevent Morphine-induced Mechanical Allodynia and Anti-allodynic Tolerance / 神经科学通报·英文版

The chronic use of morphine and other opioids is associated with opioid-induced hypersensitivity (OIH) and analgesic tolerance. Among the different forms of OIH and tolerance, the opioid receptors and cell types mediating opioid-induced mechanical allodynia and anti-allodynic tolerance remain unresolved. Here we demonstrated that the loss of peripheral μ-opioid receptors (MORs) or MOR-expressing neurons attenuated thermal tolerance, but did not affect the expression and maintenance of morphine-induced mechanical allodynia and anti-allodynic tolerance. To confirm this result, we made dorsal root ganglia-dorsal roots-sagittal spinal cord slice preparations and recorded low-threshold Aβ-fiber stimulation-evoked inputs and outputs in superficial dorsal horn neurons. Consistent with the behavioral results, peripheral MOR loss did not prevent the opening of Aβ mechanical allodynia pathways in the spinal dorsal horn. Therefore, the peripheral MOR signaling pathway may not be an optimal target for preventing mechanical OIH and analgesic tolerance. Future studies should focus more on central mechanisms.

Bloqueio epidural torácico comparado a morfina endovenosa no tratamento da dor na síndrome pós-embolização hepática: ensaio clínico randomizado controlado / Thoracic epidural block compared to intravenous morphine in the treatment of pain in hepatic post-embolization syndrome: a randomized controlled clinical trial

Introdução: A embolização e a quimioembolização transarterial hepática são procedimentos cirúrgicos usados para tratar pacientes com tumores hepáticos de origem primária e metastática, entretanto causam dor importante no período pós-operatório. O objetivo do estudo foi comparar o bloqueio epidural torácico à morfina endovenosa no tratamento da dor na síndrome pós-embolização hepática. Métodos: Foram randomizados 50 casos de pacientes submetidos a embolização transarterial hepática, os quais foram alocados em dois grupos: grupo morfina endovenosa (GV), submetido a uma dose de morfina na sala operatória; e o grupo bloqueio epidural torácico (GE), submetido a bloqueio epidural de injeção única. Todos os pacientes utilizaram analgesia endovenosa controlada pelo paciente no período pós-operatório. Foram analisados no estudo o consumo de morfina endovenosa no período pós-operatório, a dor aferida pela escala numérica verbal (ENV), o tempo de internação hospitalar, a incidência de náuseas, vômitos, prurido, retenção urinária, depressão respiratória e sonolência. Resultados: Não houve diferença do consumo médio de morfina e da ENV no período pós-operatório imediato. No primeiro dia pós-operatório o consumo médio de morfina no GV foi de 6.3 mg vs. 0.45 mg no GE, p < 0.01. A ENV no GV foi de 3.77 vs. 0.82 no GE, p<0.01. O consumo médio de morfina no período pós-operatório no GV foi de 6.91mg vs. 0.5mg no GE, p<0.01. Apenas dois pacientes do GE ficaram internados por mais de um dia, enquanto no GV oito pacientes receberam alta hospitalar a partir do segundo dia pós-operatório, entretanto não houve diferença estatisticamente significativa do tempo de internação hospitalar. Prurido foi observado em 18.2% dos pacientes do GE, e não houve ocorrência no GV, p=0.04. Conclusões: O bloqueio epidural torácico foi superior à morfina endovenosa no tratamento da dor na síndrome pós-embolização hepática.

Background: Hepatic transarterial embolization and chemoembolization are surgical procedures used to treat patients with hepatic tumors of primary and metastatic origin, however they cause significant pain in the postoperative period. The objective of the study was to compare thoracic epidural block with intravenous morphine in the treatment of pain in hepatic post-embolization syndrome. Methods: A total of 50 patients undergoing hepatic transcatheter arterial embolization were randomized and allocated into two groups: intravenous morphine group (IG) underwent to a morphine dose in the operating room; and thoracic epidural block group (EG) underwent to a single-shot epidural injection. All patients used intravenous patient-controlled analgesia (PCA) in postoperative period. Intravenous morphine consumption in the postoperative period, pain measured by the numerical rating scale (NRS), length of hospital stay, nausea, vomiting, pruritus, urinary retention, respiratory depression and drowsiness were analyzed. Results: There was no difference in the mean morphine consumption and NRS in the immediate postoperative (IPO) period. On postoperative day 1, the IG mean morphine consumption was 6.3 mg vs. 0.45 mg in EG, p<0.01. NRS in IG was 3.77 vs. 0.82 in EG, p<0.01. Morphine consumption in post-operative period in IG was 6.91 mg vs. 0.5 mg in EG, p<0.01. Only two patients in the EG were hospitalized for more than one day, while in the GV eight patients were discharged from the second postoperative day, however there was no statistically significant difference in the length of hospital stay. Pruritus was observed in 18.2% of EG patients and none in the IG, p = 0.04. Conclusions: Thoracic epidural block was superior to intravenous morphine in the treatment of pain in hepatic post embolization syndrome.

Ketamine pour la gestion de la douleur post hystérectomie au CHU Professeur Zafisaona Gabriel Mahajanga Madagascar / Ketamine for the management of post-hysterectomy pain at the Professor Zafisaona Gabriel University Hospital, Mahajanga, Madagascar

Une analgésie multimodale est incontournable pour la prise en charge de la douleur post opératoire. L'objectif de notre étude était de montrer l'intérêt de l'utilisation de la kétamine, avec son effet analgésique, parmi les différentes molécules disponibles. Méthodes : Il s'agit d'une étude prospective monocentrique en simple aveugle de 31 cas d'hystérectomie programmée sur une période de 6 mois (mai­octobre 2016) divisée en deux groupes soumis au même protocole anesthésique : un groupe recevant de la kétamine en bolus suivi d'une perfusion continue peropératoire et sur les premières 24 heures et un groupe contrôle sans kétamine. En période post opératoire les deux groupes bénéficient d'une analgésie multimodale. L'analyse statistique a été faite par le test de Student. Résultats : Les scores de douleur diffèrent peu en moyenne sur les 24 heures de surveillance, tandis qu'une épargne morphinique importante est notée dans le groupe kétamine de l'ordre de 50% avec une valeur de p<0,001 fortement significative. A côté nous n'avons constaté aucun effet indésirable notable. Conclusion : L'adjonction de kétamine même de brève durée dans la prise en charge de la douleur post opératoire a permis de baisser considérablement la consommation morphinique

Randomized Clinical Trial Comparing Quadratus Lumborum Block and Intrathecal Morphine for Postcesarean Analgesia / Ensaio Clínico Randomizado Comparando Bloqueio do Quadrado Lombar e Morfina Intratecal Para Analgesia Pós-cesariana

Abstract Objective To compare the efficacy of quadratus lumborum (QL) block and intrathecal morphine (M) for postcesarean delivery analgesia. Methods Thirty-one pregnant women with ≥ 37 weeks of gestation submitted to elective cesarean section were included in the study. They were randomly allocated to either the QL group (12.5 mg 0.5% bupivacaine for spinal anesthesia and 0.3 ml/kg 0.2% bupivacaine for QL block) or the M group (12.5 mg bupivacaine 0.5% and 100 mcg of morphine in spinal anesthesia). The visual analog scale of pain, consumption of morphine and tramadol for pain relief in 48 hours, and side effects were recorded. Results Median pain score and/or pain variation were higher in the morphine group than in the QL group (p = 0.02). There was no significant difference in the consumption of morphine or tramadol between groups over time. Side effects such as pruritus, nausea, and vomiting were observed only in the morphine group. Conclusion Quadratus lumborum block and intrathecal morphine are effective for analgesia after cesarean section. Patients undergoing QL block had lower postoperative pain scores without the undesirable side effects of opioids such as nausea, vomiting, and pruritus.

Resumo Objetivo Comparar a eficácia do bloqueio do quadrado lombar (QL) e da morfina intratecal (M) na analgesia pós-cesariana. Métodos Trinta e uma gestantes com ≥ 37 semanas de gestação submetidas a cesariana eletiva foram incluídas no estudo. Eles foram alocados aleatoriamente no grupo QL (12,5 mg de bupivacaína a 0,5% para raquianestesia e 0,3 ml/kg de bupivacaína a 0,2% para bloqueio de QL) ou no grupo M (12,5 mg de bupivacaína a 0,5% e 100 mcg de morfina na raquianestesia). A escala visual analógica de dor, consumo de morfina e tramadol para alívio da dor em 48 horas e efeitos colaterais foram registrados. Resultados A mediana do escore de dor e/ou variação da dor foi maior no grupo morfina do que no grupo QL (p = 0,02). Não houve diferença significativa no consumo de morfina ou tramadol entre os grupos ao longo do tempo. Efeitos colaterais como prurido, náuseas e vômitos foram observados apenas no grupo morfina. Conclusão O bloqueio QL e a morfina intratecal são eficazes para analgesia após cesariana. Os pacientes submetidos ao bloqueio do QL apresentaram menores escores de dor pós-operatória sem os efeitos colaterais indesejáveis dos opioides, como náuseas, vômitos e prurido.

Manejo del dolor posoperatorio en pacientes beneficiarios de una artroplastia total de rodilla: comparación de tres técnicas analgésica / Postoperative pail management in patients underfgoing total knee arthroplaty: comparison of three analgesic techniques

Introducción: La artroplastia total de rodilla (ATR) es un procedimiento quirúrgico muy doloroso en cirugía ortopédica, siendo muy difícil su tratamiento. El objetivo del presente estudio fue comparar 3 estrategias de analgesia post operatoria en el manejo del dolor post ATR. Pacientes y Método: se estudiaron 60 pacientes, divididos en 3 grupos. Grupo 1: Bloqueo iliofascial (BIFC), Grupo 2: Analgesia epidural continua (AEPIC) y Grupo 3: Morfina intratecal (MIT). Se evaluó el dolor post operatorio (DPO) en reposo y movimiento con escala visual análoga en las primeras 24 hrs., consumo de morfina endovenosa (MEV), incidencia de efectos adversos: prurito, náuseas y vómitos (NVPO), retención urinaria (RU). Al término del tratamiento se evaluó la satisfacción del paciente. Resultados: El DPO fue significativamente menor entre las 6 y 24 hrs. en los pacientes del Grupo 3 versus los de los Grupos 1 y 2 (p<0,01). El consumo de MEV fue menor en los pacientes del grupo 3 (p< 0,01). La incidencia de prurito post operatorio y RU fue significativamente mayor en el grupo 3 versus los grupos 1 y 2 (p< 0, 001 y p< 0,008). La hipotensión arterial fue mayor en los grupos 2 y 3 versus el grupo 1 (p< 0,05), siendo más frecuente la hipotensión moderada en el grupo 3 versus a los grupos 1 y 2 (p< 0.01). La calidad de la analgesia fue considerada superior en los pacientes del grupo 3. Conclusión: Las 3 técnicas analgésicas son útiles para el manejo del DPO de una ATR. La MIT presenta menor índice de dolor, mejor calidad de la analgesia percibida por el paciente, pero una mayor incidencia de efectos adversos en relación con el BIFC y AEPIC.

Introduction: Total knee arthroplasty (TKA) is a very painful surgical procedure in orthopedic surgery, making its treatmentvery difficult. The objective of the present study was to compare 3 postoperative analgesia strategies in the management of post TKA pain. Patients and Method: 60 patients, divided into 3 groups, were studied. Group 1: Iliofascial blockade (BIFC), Group 2: Continuous epidural analgesia (AEPIC) and Group 3: Intrathecal morphine (MIT). Postoperative pain (POD) at rest and movement was evaluated with a visual analog scale (EVA) in the first 24 hours, intravenous morphine consumption (VEM), incidence of adverse effects: pruritus, nausea and vomiting (PONV), urinary retention (UR). At the end of treatment, patient satisfaction was evaluated. Results: The DPO was significantly lower between 6 and 24 hours in the patients of Group 3 versus those of Groups 1 and 2 (p<0.01). MEV consumption was lower in patients of group 3 (p<0.01). The incidence of postoperative pruritus and UR was significantly higher in group 3 versus groups 1 and 2 (p<0.001 and p<0.008). Arterial hypotension was greater in groups 2 and 3 versus group 1 (p<0.05), with moderate hypotension being more frequent in group 3 versus groups 1 and 2 (p<0.01). The quality of analgesia was considered superior in patients in group 3. Conclusion: The three analgesic techniques are useful for managing the DPO of a TKA. MIT presents a lower pain index, better quality of analgesia perceived by the patient, but a higher incidence of adverse effects in relation to BIFC and AEPIC.

Associations between postoperative analgesic consumption and distress tolerance, anxiety, depression, and pain catastrophizing: a prospective observational study

Abstract Background Patients' postoperative treatment might be affected by their psychological state. The study aimed to evaluate the effects of anxiety, coping ability (stress tolerance), depression, and pain catastrophizing on analgesic consumption in patients scheduled for sleeve gastrectomy. Methods This prospective observational study consisted of 72 patients. The Distress Tolerance Scale (DTS), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) were completed in the preoperative period. In the postoperative period, pain intensity, as measured with the Visual Analogue Scale (VAS), and morphine consumption (mg) were evaluated after 2, 6, 8, and 24 hours. Total morphine consumption was recorded. Results The results revealed a strong negative correlation between distress tolerance and postoperative total morphine consumption (r = -0.702, p< 0.001). There was a strong positive correlation between total morphine consumption and pain catastrophizing (r = 0.801, p< 0.001). A moderate positive correlation was observed between total morphine consumption and anxiety and between total morphine consumption and depression (r = 0.511, p< 0.001; r = 0.556, p< 0.001, respectively). Linear regression revealed that distress tolerance, anxiety, depression, and pain catastrophizing are predictors of postoperative morphine consumption (β = 0.597, p< 0.001; β = 0.207, p= 0.036; β = 0.140, p= 0.208; β = 0.624, p< 0.001, respectively). Conclusions Distress tolerance, anxiety, depression, and pain catastrophizing can be predictive of postoperative analgesic consumption. In the estimation of postoperative analgesic consumption, distress tolerance, as well as anxiety, depression, and pain catastrophizing, were found to be important predictors.

Effect of continuous intra-incisional bupivacaine on postoperative pain in non-traumatic spinal fixation surgeries: a randomized controlled trial

Abstract Background Continuous injection of local anesthetics by using surgical wound catheters for postoperative pain relief has gained acceptance in recent years. However, whether this method can be alternatively used instead of systemic opioids in different surgical procedures has not yet been elucidated. Objectives The aim was to investigate the effect of continuous injection of bupivacaine through a catheter inside the surgical wound on reducing the postoperative pain of lumbar spine fusion surgeries. Methods In this clinical trial, 31 patients undergoing non-traumatic lumbar spine stabilization surgery were randomly assigned to receive (n = 15) or do not receive (n = 16) bupivacaine through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), dose of required morphine, and drug-related complications within 24 hours of intervention were assessed and compared by the Mann-Whitney and independent t-test. Results Mean pain intensity was significantly lower in the case group over the first postoperative hour in the recovery room (p < 0.001), which continued for the first 2 hours after entering the ward. The mean morphine intake was lower in the bupivacaine group during the first postoperative 24 hours (16 ± 0.88 vs. 7.33 ± 0.93 mg, p < 0.001). The two groups were not significantly different regarding drug-related complications. Conclusion Continuous intra-incisional infusion of bupivacaine helped better pain reduction during the early postoperative hours while sparing morphine consumption in the first postoperative day.

Administración prolongada de morfina intratecal por bomba de infusión implantada, en un caso de dolor crónico no oncológico / Prolonged administration of intratecal morphine by infusion pump implanted in a case of non-oncological chronic pain / Administração prolongada de morfina intratecal por bomba de infusão implantada, em caso de dor crônica não oncológica

Introducción: Se describe la evolución de un paciente que recibe morfina intratecal mediante una bomba de infusión, que le fuera implantada hace 14 años para tratamiento de su dolor lumbar crónico post-laminectomía. Material y método: Requería la administración de 60 mg/día de morfina subcutánea que le provocaban efectos secundarios que no toleraba, y múltiples internaciones para control del dolor. Se le implantó una bomba de infusión continua (Isomed) conectada a un catéter subaracnoideo, que libera 1 ml/día, y requiere ser llenada cada 60 días. Resultados: Se observó una disminución del dolor promedio de 50% al año, y de 75% a los 6 y 14 años. Requirió un aumento progresivo de las dosis de llenado, que pasaron de 30 mg de morfina (0.5 mg/día) al inicio, a 40 mg de morfina (0.66 mg /día) al año, a 70 mg de morfina (1.16 mg/día) a los 6 años, a 140 mg (2.33 mg/día) a los 14 años. No se registraron complicaciones médicas graves. Mantuvo constipación y sudoración durante todo el período, e instaló un hipogonadismo secundario con trastornos de la libido y de la erección que fueron corregidos con la administración de testosterona. No requirió más internaciones por dolor. No se observaron complicaciones relacionadas con el funcionamiento o llenado de la bomba, ni vinculadas al catéter. El paciente manifestó estar satisfecho con el implante. Discusión: A pesar del aumento de las dosis de llenado, expresión del desarrollo de tolerancia, las dosis de morfina/día requeridas son francamente inferiores al límite recomendado. Conclusiones: El balance del riesgo-beneficio del implante resultó positivo, considerando el mejor control del dolor logrado, las menores dosis de morfina utilizadas, así como la ausencia de complicaciones graves y de internaciones para control del dolor.

Introduction: The evolution of a patient receiving intrathecal morphine through an infusion pump that was implanted 14 years ago for the treatment of chronic post-laminectomy low back pain is described. Material and method: It required the administration of 60 mg / day of subcutaneous morphine that caused side effects that did not tolerate, and multiple hospitalizations for pain control. He was implanted with a continuous infusion pump (Isomed) connected to a subarachnoid catheter, which releases 1 ml / day, and needs to be filled every 60 days. Results: An average pain decrease of 50% per year, and 75% at 6 and 12 years was observed. It required a progressive increase in filling doses, which went from 30 mg of morphine (0.5 mg / day) at the beginning, to 40 mg of morphine (0.66 mg / day at the first year, to 70 mg of morphine (1.16 mg / day) at the sixth year, at 140 mg (2.33 mg / day) at the fourteen year. No serious medical complications were recorded, he maintained constipation and sweating throughout the period, and installed secondary hypogonadism with libido and erection disorders, that were corrected with the administration of testosterone. No further hospitalizations were required due to pain. No complications were observed related to the operation or filling of the pump or linked to the catheter. The patient stated that he was satisfied with the implant. Discussion: Despite the increase in filling doses, expression of tolerance development, the required morphine / day doses are frankly below the recommended limit. Conclusions: The risk-benefit balance of the implant was positive, considering the best pain control, the lowest doses used, the absence of serious complications, and the lack of hospitalizations for pain control.

Introdução: Descreve-se a evolução de um paciente que recebeu morfina intratecal através de uma bomba de infusão, implantada há 14 anos para o tratamento de lombalgia crônica pós-laminectomia. Material e método: Necessitou de administração de 60 mg/dia de morfina por via subcutânea, que provocou efeitos colaterais intolerantes, e múltiplas internações para controle da dor. Foi implantada uma bomba de infusão contínua (Isomed) conectada a um cateter subaracnóideo, que libera 1 ml/dia, necessitando de reenchimento a cada 60 dias. Resultados: Observou-se redução média da dor de 50% em um ano e 75% em 6 e 14 anos. Foi necessário um aumento progressivo das doses de enchimento, que passaram de 30 mg de morfina (0,5 mg/dia) no início, para 40 mg de morfina (0,66 mg/dia) por ano, para 70 mg de morfina (1,16 mg/dia) dia) aos 6 anos, para 140 mg (2,33 mg/dia) aos 14 anos. Não foram registradas complicações médicas graves. Manteve constipação e sudorese durante todo o período e desenvolveu hipogonadismo secundário com distúrbios de libido e ereção que foram corrigidos com administração de testosterona. Ele não necessitou de mais hospitalizações por dor. Não foram observadas complicações relacionadas à operação ou enchimento da bomba, ou relacionadas ao cateter. O paciente afirmou estar satisfeito com o implante. Discussão: Apesar do aumento das doses de enchimento, expressão do desenvolvimento da tolerância, as doses necessárias de morfina/dia são francamente inferiores ao limite recomendado. Conclusões: A relação risco-benefício do implante foi positiva, considerando o melhor controle da dor alcançado, as menores doses de morfina utilizadas, bem como a ausência de complicações graves e internações para controle da dor.

Estudio cuasi experimental: analgesia intratecal Clonidina vs Morfina para manejo del dolor postoperatorio inmediato en cirugías de columna / QUASI-EXPERIMENTAL STUDY: CLONIDINE INTRATHECAL ANESTHESIA VS. MORPHINE FOR IMMEDIATE POSTOPERATIVE PAIN MANAGEMENT IN SPINE SURGERY

Introducción: El manejo inmediato del dolor postoperatorio es esencial para una comodidad y rehabilitación temprana del paciente Este estudio busca evaluar el efecto analgésico postoperatorio inmediato en cirugías de columna lumbosacra por vía posterior, como los efectos adversos con la administración de analgesia intratecal, usando Clonidina contra Morfina. Material y métodos: Es un estudio analítico de intervención, cuasi experimental, prospectivo, longitudinal, comparativo, doble ciego. Para comparar la eficacia de la analgesia intratecal post operatoria inmediata en cirugías de columna lumbosacra primarias por vía posterior y los efectos adversos. Los pacientes se distribuyeron en dos grupos previamente designados, a un grupo se le administro Clonidina 0.5 microgramos/kg/peso y a otro grupo Morfina 5 microgramos/Kg/Peso. intratecal, intraoperatorio. Resultados: Existió diferencia estadísticamente significativa con mejor manejo del dolor postoperatorio en las primeras horas y menor presencia de vómitos en el grupo de pacientes que se utilizó Clonidina intratecal. No existió diferencia estadísticamente significativa de ambas medicaciones intratecales en la valoración de otros efectos adversos. Discusión: El uso de la analgesia intratecal ha ido ganando relevancia en el tiempo y se fueron sumando estudios para ver la eficacia de diferentes medicamentos, diferentes dosis, menor presencia de efectos adversos. El estudio analiza estas variables buscando una mejor opción terapéutica. Tenemos a favor una muestra representativa a pesar de no ser aleatoria, estricto seguimiento, y análisis estadístico adecuado. Conclusión: La Clonidina intratecal es más efectiva para manejo del dolor post operatorio inmediato de cirugías de columna lumbosacra por vía posterior y con menor presencia de efectos adversos

Introduction: Immediate postoperative pain management is essential for the patient's greater comfort and early rehabilitation. Te goal of this study is to evaluate the immediate analgesic postoperative effect in posterior lumbosacral spine surgery, as well as the adverse effects of the administration of intrathecal analgesia, using Clonidine versus Morphine. Material and methods: An analytical, quasi-experimental, prospective, longitudinal, comparative, double-blinded intervention study was conducted to compare the efficacy of immediate postoperative intrathecal analgesia in primary posterior lumbosacral spine surgery, and the adverse effects. Te patients were divided into two previously designated groups. One group received Clonidine 0.5 microgramos/kg and the other group received Morphine 5 microgramos/kg. Intrathecal, intraoperative. Results: Tere was a statistically significant difference with better postoperative pain management in the first hours and less vomiting in the group of patients who received intrathecal Clonidine. Tere was no statistically significant difference between both intrathecal medications in the evaluation of other adverse effects. Discussion: Te use of intrathecal analgesia, has been on the rise over time and more studies have been conducted to see the efficacy of different drugs, different doses, with fewer adverse effects. Tis study to analyze these variables with a view to finding a better therapeutic option. Te advantage is having a representative if not random sample, strict follow-up, and appropriate statistical analysis Conclusion: Intrathecal Clonidine proved to be more effective in immediate postoperative pain management after posterior lumbosacral spine surgery and with fewer adverse effects

Low-level laser acupuncture reduces postoperative pain and morphine consumption in older patients with total knee arthroplasty: A randomized placebo-controlled trial / 中西医结合学报

BACKGROUND@#Patients commonly develop postoperative pain after total knee arthroplasty (TKA). Acupuncture-related techniques and low-level laser therapy could be beneficial for pain management for older individuals.@*OBJECTIVE@#To examine the effect of low-level laser acupuncture (LA) in reducing postoperative pain, pain-related interference in daily life, morphine consumption, and morphine-related side effects in older patients with knee osteoarthritis who underwent TKA.@*DESIGN, SETTING, PARTICIPANTS AND INTERVENTION@#A single-blind randomized placebo-controlled trial was conducted. Patients (N = 82) were recruited and randomly assigned via a computer-generated list to the LA group or a placebo group. The LA group received low-level laser therapy at Sanyinjiao (SP6), Taixi (KI3), Kunlun (BL60), Fengshi (GB31), Futu (ST32) and Neiguan (PC6) after TKA, while the placebo acupuncture group received the same treatment procedure without laser energy output.@*MAIN OUTCOME MEASURES@#The primary outcome was postoperative pain intensity, and it was measured at baseline and hours 2, 6, 10, 24, 48 and 72 after TKA. The secondary outcomes, including relative pain, postoperative pain-related interference in daily life and morphine consumption, were measured at hours 24, 48 and 72 after TKA.@*RESULTS@#Generalized estimating equations revealed significant between-group differences in pain intensity (P = 0.01), and trend differences in pain intensity for the LA group starting at hours 10 to 72 (P < 0.05) and morphine consumption at hours 48 and 72 (P < 0.05). The changes in pain-related interference in daily life were significant (P < 0.05) at 72 h, with the exception of the parameters for worst pain, mood, and sleep. Nausea and vomiting side effects from morphine had significant between-group differences at hours 10 and 24 (P < 0.05).@*CONCLUSION@#Low-level LA gradually reduced older patients' postoperative pain intensity and morphine consumption within the first 72 h after their TKA for osteoarthritis. Low-level LA may have benefits as an adjuvant pain management technique for clinical care.@*TRIAL REGISTRATION@#ClinicalTrials.gov registration number NCT03995446.

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.

Insulin replacement prevents the acquisition but not the expression of morphine-induced conditioned place preference in streptozotocin-induced diabetic rats

Abstract Insulin receptors have distributed in all brain regions, including the nucleus Accumbens (NAc), and where is implicated in the reward properties of drugs. It is well known that insulin signaling can regulate dopamine release. Therefore, in the present study, we tried to examine the effect of insulin replacement on the acquisition and expression of morphine-induced conditioned place preference (CPP) in diabetic rats. Forty-eight male Wistar rats were divided into two non-diabetic (Naïve) and diabetic groups rendered by a single injection of streptozotocin (STZ). These groups separately received insulin (10U/kg) or saline (1 ml/kg) one hour prior to morphine administration (5mg/kg;s.c.) during conditioning days (acquisition phase) or post-conditioning day (expression phase) in the CPP paradigm. In this paradigm, conditioning score (CS) and locomotion activity were recorded by Ethovision. The STZ-induced diabetic rats displayed higher CS compared to naïve rats (P<0.05). This effect was abolished in all diabetic rats that received insulin during conditioning days but not the expression phase. This study has provided evidence that insulin plays a modulatory role in morphine-induced CPP, and insulin replacement during the acquisition phase could reduce the rewarding properties of morphine in diabetes conditions through a possible modulating effect on dopamine release in the NAc region

Riesgo de la prescripción de opioides para el manejo del dolor / Risk of Opioid Prescriptions for Management of Pain / Risco de prescrição de opioides para o tratamento da dor

actualmente existe una intensa prescripción de opioides para el manejo de todo tipo de dolor a nivel clínico, razón por la cual es importante considerar los posibles daños derivados de esta actividad, tales como tolerancia, adicción, dependencia y sobredosis. La medicación de opiáceos o sus derivados de manera irracional para el manejo del dolor agudo o crónico puede ser la puerta de entrada a las drogodependencias. Muchos adictos a opiáceos informaron haber estado expuestos por primera vez a los opioides a través de una prescripción médica para el tratamiento del dolor. Por ello, es importante evaluar por parte de los profesionales de la salud el uso a largo plazo de estos medicamentos para el manejo del dolor, porque estudios han evidenciado una relación entre el uso clínico y la dependencia de estos, sobre todo en adolescentes y adultos jóvenes sin experiencia en opiáceos que fueron sometidos a procedimientos quirúrgicos y dentales.

Currently, opioids for managing all types of pain are increasingly prescribed at the clinical level, which is why it is important to consider the potential harms derived from this practice, such as tolerance, addiction, dependence, and overdose. Irrational medication of opioids or opioid derivatives for acute or chronic pain management can be the gateway to drug dependence. Many opioid addicts reported first being exposed to opioids after receiving a physician's prescription for pain management. Therefore, health professionals need to evaluate the long-term use of these medications to manage pain because studies have shown a relationship between clinical use and opioid dependence, especially in adolescents and young adults who had never received opioid therapy and who underwent surgical and dental procedures

Atualmente existe uma intensa prescrição de opioides para o manejo de todos os tipos de dor em nível clínico, por isso é importante considerar os possíveis danos decorrentes dessa atividade, como tolerância, adição, dependência e overdose. A medicação de opiáceos ou seus derivados de forma irracional para o manejo da dor aguda ou crônica pode ser a porta de entrada para a adição a drogas. Muitos dependentes de opioides relataram ter sido expostos a opioides pela primeira vez por meio de uma receita médica para o tratamento da dor. Por esse motivo, é importante que os profissionais de saúde avaliem o uso prolongado desses medicamentos para o manejo da dor, pois estudos têm mostrado relação entre o uso clínico e a dependência dos mesmos, principalmente em adolescentes e adultos jovens sem experiência com opioides que foram submetidos a procedimentos cirúrgicos e odontológicos

Chemical composition of Zhumeria majdae essential oil and its effects on the expression of morphine withdrawal syndrome and tolerance to the anticonvulsant effect of morphine on pentylenetetrazole-induced seizures in mice / Composição química do óleo essencial de Zhumeria majdae e seus efeitos na expressão da síndrome de abstinência de morfina e tolerância ao efeito anticonvulsivante da morfina em crises induzidas por pentilenotetrazol em camundongos

Abstract Regarding the proven anticonvulsant effect of Zhumeria majdae essential oil (ZMEO) in previous studies we were prompted to investigate the ZMEO effects on the tolerance to the anticonvulsant effects of morphine and the morphine withdrawal syndrome. Tolerance to the morphine anticonvulsant effect was induced in mice by subcutaneous injection of 2.5 mg/kg of morphine for 4 days. Subsequent doses of ZMEO (20 mg/kg) were used to study the expression and development of morphine tolerance. Clonidine was used as the standard drug to inhibit the morphine withdrawal syndrome symptoms. To study the ZMEO effect on withdrawal syndrome, mice received appropriate morphine values for 4 days and on the fifth day, 60 min before administration of naloxone. The effective dose of ZMEO was determined and the number of jumps, stands and changes in the dry stool weight, as symptoms of withdrawal syndrome were evaluated. The dose of 20 mg/kg of ZMEO decreased the tolerance in development and expression groups significantly. Counting the number of jumping, standing and defecation were assessed 30 min after morphine and 1 h after the vehicle and clonidine. The dose of 40 mg/kg ZMEO decreased all the signs of withdrawal syndrome significantly. ZMEO was analyzed by GC/MS and linalool (53.1%) and camphor (23.8%) were characterized as the main components. The results suggest that ZMEO possesses constituent(s) that have activity against tolerance to the anticonvulsant effects of morphine and the morphine withdrawal symptoms.

Resumo Em relação ao efeito anticonvulsivante comprovado do óleo essencial de Zhumeria majdae (ZMEO) em estudos anteriores, fomos instigados a investigar os efeitos do ZMEO em relação à tolerância aos efeitos anticonvulsivantes da morfina e da síndrome de abstinência de morfina. A tolerância ao efeito anticonvulsivante da morfina foi induzida em camundongos por injeção subcutânea de 2,5 mg/kg de morfina por 4 dias. Doses subsequentes de ZMEO (20 mg/kg) foram utilizadas para estudar a expressão e o desenvolvimento da tolerância à morfina. A clonidina foi usada como droga padrão para inibir os sintomas da síndrome de abstinência da morfina. Para estudar o efeito do ZMEO na síndrome de abstinência, os camundongos receberam valores apropriados de morfina por 4 dias e, no 5º dia, 60 minutos antes da administração de naloxona. A dose efetiva de ZMEO foi determinada, e o número de saltos e de permanência e as alterações no peso das fezes secas, conforme os sintomas da síndrome de abstinência, foram avaliados. A dose de 20 mg/kg de ZMEO diminuiu significativamente a tolerância nos grupos de desenvolvimento e expressão. A contagem do número de saltos, permanência e defecação foi avaliada 30 minutos após a morfina e 60 minutos após o veículo e a clonidina. A dose de 40 mg/kg de ZMEO diminuiu significativamente todos os sinais da síndrome de abstinência. O ZMEO foi analisado por GC/MS, e linalol (53,1%) e cânfora (23,8%) foram caracterizados como os principais componentes. Os resultados sugerem que o ZMEO apresenta constituintes que possuem atividade contra a tolerância aos efeitos anticonvulsivantes da morfina e aos sintomas de abstinência da morfina.