A Randomized Controlled Trial Evaluating the Analgesic Effect of the Combination of Methadone With Morphine for Cancer Related Pain.

CONTEXT AND OBJECTIVES: Although opioids play an indispensable role in the management of cancer-related pain, inadequate pain relief still occurs. The primary objective of this study was to evaluate whether the combination of a low dose of methadone with morphine promotes a reduction in opioid consumption; the secondary objectives were if the association promotes lower pain intensity, and adverse effects (AEs). MATERIALS AND METHODS: A sample if 41 patients with cancer-related pain in palliative setting were included. Patients were starting the third step of the analgesic ladder, and 1 group (n=21) achieve methadone (2.5 mg/12 h) in combination with morphine/methadone, and another group (n=20) received morphine alone. Both groups could use morphine (5 mg) as needed to maintain pain intensity <4, and adjuvant in stable dose. The following outcomes were evaluated: total morphine dose, pain intensity, and AEs. RESULTS: There was no difference in the number of adjuvants, and the dose of morphine used. Pain intensity was significantly lower in the morphine/methadone group after 2 weeks, with no statistically significant difference at other timepoints. There was no difference between groups in the AEs. CONCLUSION: Low dose of methadone in combination with morphine provided faster pain control as compared with morphine alone, and although this study was not powered to show differences in AEs, we did not notice a difference.

Retrospective Study of the Analgesic Effect of Sacroiliac Joint Radiofrequency Denervation.

BACKGROUND: Interventional radiofrequency (RF) ablation techniques are indicated when an adequate effect is not obtained with conservative measures. OBJECTIVES: The primary objective of this study was to evaluate pain relief after RF denervation of the sacroiliac joint. The secondary objective was to evaluate pain intensity and relief duration. STUDY DESIGN: The study was retrospective. SETTING: The study was conducted at Vera Cruz Hospital, Campinas, Brazil. METHODS: Data were collected from the medical records of patients undergoing RF denervation for low back pain originating in the sacroiliac joint, from January 2015 to December 2017. There were 78 patients studied, between 18 and 65 years old, of both genders, ASA I or II, who underwent knee arthroscopic meniscectomy. The patients were submitted to denervation of sacroiliac joint by 3 types of RF (conventional, pulsed, and cooled). The following parameters were evaluated, number of patients who obtained ? 50% pain relief; pain intensity, measured using the visual analog scale (before the procedure and 15, 30, 90 and 180 days after, performed by the same evaluator); and the use of complementary analgesic for 2 weeks. RESULTS: Of the 78 included patients, 56 (71.8%) underwent conventional RF, 9 (11.5%) underwent pulsed RF, and 13 (16.7%) underwent cooled RF. There were losses to follow-up including 40 patients who underwent conventional RF, 5 who underwent pulsed RF, and 12 who underwent cooled RF, who were retained for 6 months. There was significant pain relief with the three types of RF for up to 6 months of follow-up, with no difference among the types. After 6 months, 90.2% of patients who underwent conventional RF, 100% who underwent pulsed RF, and 91.7% who underwent cooled RF maintained ≥ 50% pain relief. Complementary analgesics were used by 95% of the patients who underwent conventional RF, 80% who underwent pulsed RF, and 91% who underwent cooled RF 2 weeks after the procedure. There were mild adverse effects, such as edema, hematoma, and local pain, without complications. LIMITATIONS: As for limitations, the number of pulsed and cooled RF is low and in a retrospective study some data may be missing, especially from follow-up. CONCLUSIONS: RF denervation of the sacroiliac joint is effective and promotes a long-lasting analgesic effect.

Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study.

CONTEXT AND OBJECTIVE: Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation. OBJECTIVE: The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair. MATERIALS AND METHODS: Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control. RESULTS: There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005). DISCUSSION: A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.

Randomized, Double-Blind Study of the Effect of Intraoperative Intravenous Lidocaine on the Opioid Consumption and Criteria for Hospital Discharge After Bariatric Surgery.

BACKGROUND AND OBJECTIVES: Surgical trauma, pain and opioids can cause nausea, vomiting, ileus and increased length of hospital stay. The primary objective of the study was to evaluate the time to recovery of gastrointestinal function and the time to meet hospital discharge criteria after laparoscopic bariatric surgery with intraoperative intravenous lidocaine administration. Secondary objectives were to evaluate morphine consumption during the first 24 h and the side effects of opioids. METHODS: Fifty-eight patients aged 18 to 60 years who underwent bariatric surgery were allocated into two groups. Group 1 patients received intravenous lidocaine (1.5 mg/kg) 5 min before induction of anaesthesia, followed by infusion (2 mg/kg/h) until the end of surgery. Group 2 patients were given 0.9% saline solution (placebo) and infusion of 0.9% saline solution during surgery, in same volume as group 1. Anaesthesia was performed with fentanyl (5 µg/kg), propofol (2 mg/kg), rocuronium (0.6 mg/kg) and sevoflurane. Postoperative patient-controlled analgesia was with morphine. There were two groups that were evaluated: time to recovery of gastrointestinal function and time to meet discharge criteria. RESULTS: There was no significant difference between groups regarding the time to first flatus, time to meet discharge criteria and occurrence of side effects. Consumption of intraoperative sevoflurane and morphine over 24 h was significantly lower in the lidocaine group. Side effects observed were nausea and vomiting, with no difference between groups. CONCLUSIONS: Perioperative intravenous lidocaine is feasible and easily accessible when administered at appropriate doses. Lidocaine reduces morphine consumption.

Evaluation of the effect of ketamine on remifentanil-induced hyperalgesia: a double-blind, randomized study.

STUDY OBJECTIVE: Opioids are associated with hyperalgesia that can reduce their analgesic effect. The aim of this study was to determine whether the addition of ketamine reduces remifentanil-induced hyperalgesia; improves its analgesic effect; and alters interleukin 6 (IL-6), IL-8, and IL-10 levels. DESIGN: This is a prospective, randomized, double-blind study. SETTING: The setting is in a operating room and ward in a university hospital. PATIENTS: There are 56 patients, aged ≥18 years, American Society of Anesthesiologists I or II, who underwent laparoscopic cholecystectomy. INTERVENTIONS: Anesthesia was induced with remifentanil, 50% oxygen, and isoflurane. Patients randomized to group 1 received remifentanil (0.4 µg/kg per minute) and ketamine (5 µg/kg per minute), and patients randomized to group 2 received remifentanil (0.4 µg/kg per minute) and saline solution. Postoperative analgesia was achieved using morphine via patient-controlled analgesia. MEASUREMENTS: The measurements were postoperative pain intensity during 24 hours; morphine consumption; time to first morphine supplementation; hyperalgesia (using monofilaments and an algometer) and allodynia (using a soft brush) in the thenar eminence of the nondominant hand and in the periumbilical region 24 hours after surgery; extent of hyperalgesia using a 300-g monofilament near the periumbilical region 24 hours after surgery; and serum levels of IL-6, IL-8, and IL-10. MAIN RESULTS: Groups were similar for baseline characteristics. There were no differences in pain intensity, time to first request of morphine, and total 24 hours dose of morphine between groups. There was a difference in hyperalgesia using monofilaments 24 hours after the surgery in the thenar eminence of the nondominant hand, with a better profile for the experimental group. However, there were no differences in hyperalgesia using an algometer, in allodynia using a soft brush; in extent of hyperalgesia; or in levels of IL-6, IL-8, and IL-10. CONCLUSIONS: It was not possible to demonstrate that the addition of ketamine (5 µg/kg per minute) is effective in preventing or reducing remifentanil-induced postoperative hyperalgesia in laparoscopic cholecystectomy.

Comparison of acupuncture to injection for myofascial trigger point pain.

OBJECTIVES: Many treatments have been proposed for myofascial pain syndrome. The objective of this study was to compare the analgesic effect of acupuncture to trigger point injection combined with cyclobenzaprine chlorhydrate and sodium dipyrone. METHODS: A randomized study was performed in 30 patients divided into 2 groups: G1 received trigger point injection with 0.25% bupivacaine twice weekly, and both cyclobenzaprine chlorhydrate 10 mg/day and sodium dipyrone 500 mg every 8 hours; G2 received classical and trigger point acupuncture twice weekly. All patients were instructed in physical exercise. The following parameters were evaluated: pain intensity rated on a numerical scale, number of trigger points, and quality of life before and 4 weeks after treatment. RESULTS: The pain scores and the number of trigger points reduced significantly in both groups, with no significant difference between groups. Significant improvement in the quality of life scores was observed for some of the functional domains in the 2 groups, whereas there was no improvement of the general health status domain in either group or of the emotional domain in G1. CONCLUSION: Acupuncture, when compared with trigger point injection, combined with cyclobenzaprine chlorhydrate and sodium dipyrone provided similar pain relief and improvement in quality of life measures at 4 weeks.

Effect of intravenous lidocaine on manifestations of fibromyalgia.

BACKGROUND AND OBJECTIVES: The objective of our study was to evaluate the effect of intravenous lidocaine on the manifestations of fibromyalgia. METHODS: A randomized, double-blind, comparative study was conducted on 30 patients. All patients received 25 mg amitriptyline. Group 1 (n = 15) received 125 mL of saline; group 2 (n = 15) received 240 mg lidocaine in 125 mL of saline once a week for 4 weeks. The following parameters were evaluated: clinical manifestations before and 4 weeks after treatment; pain intensity on a numerical scale. RESULTS: All patients were female, and the mean age was 44.7 +/- 10.5 years in group 1 and 40.9 +/- 11.6 years in group 2. No difference in pain intensity or the number of tender points was observed between groups at any time point. Both groups demonstrated a significant decrease in the two parameters after treatment. A significant reduction in sleep disorders, paresthesia, and headache was observed after treatment in the two groups, but there was no significant difference between groups. There was no significant reduction in fatigue, subjective edema or morning stiffness after treatment in either group, without a significant difference between groups. CONCLUSIONS: The addition of 240 mg intravenous lidocaine (once a week) to 25 mg amitriptyline for 4 weeks did not modify pain intensity or manifestations in patients with fibromyalgia compared with amitriptyline alone.

Avaliação da cetamina oral para dor neuropática / Evaluation of oral cetamin for the treatment of neuropathic pain

Justificativa e objetivos: Dor neuropática é decorrente de lesão ou disfunção do sistema nervoso periférico ou central. Os antagonistas de receptores NMDA, como a cetamina, podem ser usados para dor neuropática(1), entretanto existem controvérsias sobre a eficácia desses medicamentos para redução da quantidade de outros fármacos (antidepressivos e anticonvulsivantes). O objetivo desse estudo foi avaliar o efeito da cetamina oral para dor neuropática. Método: Foram avaliados de maneira aleatória e duplo-encoberta 30 pacientes adultos portadores de dor neuropática, divididos em dois grupos. Os do G-1 (n= 15) receberam amitriptilina (25 mg) + carbamazepina (600 mg) + cetamina (30 mg/dia) os do G-2 (n= 15) amitriptilina (25 mg/dia) + carbamazepina (600 mg/dia). Quando houve necessidade de complementação analgésica foi administrada codeína (30 mg). Os pacientes foram avaliados quanto à intensidade, semanalmente durante quatro semanas, através da escala numérica. Resultados: O estudo foi completado por 23 (G1= 10 e G2= 13). Houve necessidade de complementação em cinco no G1 e um no G2. A melhora da intensidade dor foi maior no G1 (T0= 7.3±1.76 X 6.95±1.81 T7= 4.7±2.8 X 6.75±1.71 T14= 3.7±2.75 X 5.16±1.8 T21= 3.9±2.72 X 5.16±2.88 T28= 2.6±2.17 X 4.66±2.74), porém sem diferença estatística Teste de Mann Whitney. Os efeitos colaterais mais freqüentes foram: sonolência, xerostomia, tontura, taquicardia, epigastralgia e constipação. Conclusões: Não houve aumento estatisticamente significante do alívio da dor com associação de cetamina oral a amitriptilina e carbamazepina.

Estudo comparativo entre rtopivacaína e bupivacaína por via epidural para operações abdominais / Comparative study of epidural ropivacaine and rubivacaine for abdominal surgery

Justificativa e objetivos - A dor provoca alterações neuroendócrino metabólicas, com catabolismo, complicações pulmonares, alterações gastrointestinais e tromboembolismo, prejudicando a recuperação do paciente. O objetivo do estudo foi avaliar a ação analgésica e os efeitos colateraís da ropívacaína, comparando-os com os da bupivacaína associados a fentaníla. Método - 20 pacientes, de ambos os sexos e idade entre 18 e 65 anos, ASA I e II, submetidos a operações abdominais, foram divididos aleatoriamente em dois grupos.- G 1 (n= 1 0): 15 ml de ropivacaína 0,2 por cento sem vasoconstritor,- e G2 (n= 10): 15 ml de bupívacaína 0,25por cento sem vasoconstrítor associados à fentanila (50 mcg), por via epidural. Instalou-se a bomba ACP (4 ml/h - infusão contínua) de solução de ropivacaína 0, 1 por cento associada a fentaníla 0, 0005por cento (G 1) e bupivacaína 0, 1 por cento com fentaníla 0, 0005por cento (G2). A indução anestésica foi realizada com diprivam, seguida de bloqueio neuromuscular e intubação orotraqueal Para manutenção da anestesia foram utilizados isoflurano / N2 0/ 02 50por cento. Quando necessário, administrou-se anestésico local (5ml). No pós-operatório, além da infusão, os pacientes utilizaram ACP como forma de administração de anestésicos locais, de acordo com a divisão dos grupos, durante 24 horas. Havendo necessidade de complementação da analgesia no pós-operatórío, foi feito dipirona (1 g, IV). Avaliou-se a analgesia no intra-operatório pela necessidade de complementação com anestésico local e da quantidade de agente inalatórío usada. No pós-operatório, avaliaram-se a analgesia e o bloqueio motor nos períodos de 0-24 horas. A intensidade da dor foi avaliada pela escala verbal e o bloqueio motor pela escala de Bromage. Foram anotados os possíveis efeitos adversos. Resultados - Houve maior consumo de agente inalatório no Gl que no G2 (p = 0,0232), teste de Mann-Whitney. Em relação aos efeitos colaterais, registrou-se os seguintes resultados: sonolência (todos os pacientes de am- bos os grupos), náusea (8 do G 1 e 5 do G2), vômito (3 do G 1 e 3 do G2), prurido leve (3 do G 1 e zero do G2), mal-estar (2 do G 1 e zero do G2) e retenção urináría (zero do G 1 e 1 do G2). Conclusão - Pode-se concluir que as soluções de bupivacaína 0, 1 por cento e de ropivacaína 0, 1 por cento associadas ao fentanil são eficazes e com mínimos bloqueios motores.

Eficácia dos antidepressivos para dor crônica / Effectiveness of antidepressants for chronic pain

Há evidências de que os antidepressivos tricíclicos säo eficazes para dor neuropática. Entretanto,os efeitos colaterais limitam seu uso. Os inibidores seletivos da recaptaçäo de serotonina e os atípicos causam menos efeitos colaterais. Para avaliar o efeito analgésico dessas medicaçöes foi feita pesquisa (Medline, Cinhah, ,PsycLIT and Cochrane Library) de estudos em lingua inglesa de 1966 a 2000. As medicaçöes avaliadas foram : trazodona, nefazodona, paroxetina, citalopram, sertralina, fluoxetina e venlafaxina. Os estudos säo insuficientes para estabeleceer eficácia dos antidepressivos ISRS e atípicos para alívio da dor.(au)

Avaliaçäo do droperidol no alívio dos efeitos colaterais provocados pela morfina por via peridural / Evaluation of droperidol for relief of epidural morphine side effects

Os opióides por via epidural promovem analgesia superior a por via sistêmica, com menos sedaçäo. Além disso, proporciona analgesia sem bloqueios simpático e motor. A morfina é um dos opióides mais utilizados e possui duraçäo de açäo prolongada, porém sua migraoäo cranial é responsável por efeitos colaterais como prurido e vômito. Alguns estudos mostram que o droperidol pode reduzir a incidência e a gravidade do prurido. O objetivo deste estudo foi avaliar a eficácia do droperidol por via peridural em diminuir a incidencia e intensidade do prurido, da náusea e do vômito. Foram estudadas 42 pacientes adultas, ASA-I/II, submetidas a histerectomia, distrtibuídas em dois grupos: GL-anestesia peridural com 120 mg de bupivacaína 0,5 porcento e adrenalina mais 2 mg de morfina e 2,5 mg de droperidol e as do GII, 120 mg de bupivacaína 0,5 porcento mais 2 mg de morfina e 1 ml de soluçäo salina. A complementaçäo foi feita com 5 ml de bupivacaína 0,5 porcento. Avaliaçöes: término dda operaçäo (TO) e após 2,6,12 e 24 horas. Foram registrados os efeitos colaterais: prurido, náusea e vômito. Resultados: Foi observado prurido em 10 porcento das pacientes do GI e 95,3 porcento do GII, sendo a diferença significante. Foi observado prurido moderado/intenso em 57,3 porcento das pacientes do GII e 0 porcento em GI. O inicio do prurido foi observado at'e 6 horas após a injeçäo peridural. Foi observada nausea em 90 porcento das pacientes do GII e em 5 porcento do GI, sendo esta diferença significante. Ocorreu vômito em 43 porcento das pacientes do GII e 5 porcento do GI, sendo esta diferença significante. Seis pacientes do GI e nenhuma do GII apresentaram sonolência com diferença significante. Conclusäo: O uso do droperidol peridural na dose de 2,5 mg foi eficaz em reduzir a incidência de náusea, vômito e prurido provocados pela morfina peridural, porém provocou sonolência nas pacientes.(au)