Manifestaciones clínicas post supresión de sedoanalgesia en pacientes adultos de una terapia intensiva / Clinical manifestations after suppression of sedoanalgesia in adult patients in intensive care

Introducción: en la unidad de cuidados intensivos (UCI), las personas asistidas con patologías relevantes se encuentran bajo sedación, una vez que estas se encuentran bajo los principios de supresión de la sedación, es importante identificar cuáles son las manifestaciones que presentan, propias de las sedaciones. Objetivo: describir las manifestaciones clínicas del síndrome de supresión de la sedoanalgesia presentes en pacientes asistidos en un Hospital Público de la Ciudad de Corrientes de enero a diciembre del 2022. Metodología: estudio cuantitativo, descriptivo, transversal y observacional. La muestra incluyó pacientes adultos de UCI. El cálculo del tamaño muestral se realizó a través del método probabilístico aleatorio simple resultando de éste una muestra de 100 historias clínicas. Para la recolección de datos se utilizó la observación y como instrumento un formulario semiestructurado, de carácter anónimo. Cada formulario contenía datos específicos donde se categorizan las variables en estudio como ser edad, sexo, comorbilidades, tiempo de sedoanalgesia, tipo de sedación, sedoanalgesia utilizada, agitación, confusión, alucinación, diaforesis, taquicardia. Resultados: en cuanto a la edad se obtuvo un promedio de 49 años, el sexo predominante fue el masculino con 52%, en cuanto a las comorbilidades más frecuentes, el 20% presentó Insuficiencia Respiratoria Aguda y el 16% Insuficiencia renal. El motivo de ingreso a UCI en mayor medida con el 33% fue por dificultad respiratoria y Post Quirúrgicos complicados 32%. Los fármacos de mayor elección fueron midazolam 94%, seguido del fentanilo 80%. En cuanto al tiempo de sedación de los pacientes, se encontró una media de 1265 horas. Las manifestaciones clínicas que se observaron en la muestra en mayor medida corresponden a taquicardia 70%, agitación 52%, un 37% confusión e hipertensión y un 24% alucinación. Conclusión: las manifestaciones que se presentaron con mayor frecuencia fueron taquicardia, agitación, confusión, hipertensión y con menor frecuencia alucinación[AU]

Introduction: in the intensive care unit (ICU), people treated with relevant pathologies are under sedation. Once they are under the principles of sedation suppression, it is important to identify the manifestations they present, typical of sedations. Objective: To describe the clinical manifestations of sedation suppression syndrome present in patients treated at a Public Hospital in the City of Corrientes from January to December 2022. Methodology: quantitative, descriptive, cross-sectional and observational study. The sample included adult ICU patients. The calculation of the sample size was carried out through the simple random probabilistic method, resulting in a sample of 100 medical records. Manifestaciones clínicas post supresión de sedoanalgesia en pacientes adultos de una terapia intensiva. Observation was used to collect data and a semi-structured, anonymous form was used as an instrument. Each form contained specific data where the variables under study were categorized, such as age, sex, comorbidities, sedation time, type of sedation, sedation used, agitation, confusion, hallucination, diaphoresis, tachycardia. Results: regarding age, an average of 49 years was obtained, the predominant sex was male with 52%, regarding the most frequent comorbidities, 20% presented Acute Respiratory Failure and 16% Renal failure. The reason for admission to the ICU to a greater extent with 33% was due to respiratory difficulty and complicated Post-Surgeries 32%. The drugs of greatest choice were midazolam 94%, followed by fentanyl 80%. Regarding the sedation time of the patients, an average of 1265 hours was found. The clinical manifestations that were observed in the sample to a greater extent correspond to tachycardia 70%, agitation 52%, confusion and hypertension 37% and hallucination 24%. Conclusion: the manifestations that occurred most frequently were tachycardia, agitation, confusion, hypertension and, less frequently, hallucination[AU]

Introdução: na unidade de terapia intensiva (UTI), as pessoas tratadas com patologias relevantes estão sob sedação. Uma vez sob os princípios da supressão da sedação, é importante identificar as manifestações que apresentam, típicas das sedações. Objetivo: Descrever as manifestações clínicas da síndrome de supressão da sedação presentes em pacientes atendidos em um Hospital Público da Cidade de Corrientes no período de janeiro a dezembro de 2022. Metodologia: estudo quantitativo, descritivo, transversal e observacional. A amostra incluiu pacientes adultos internados em UTI. O cálculo do tamanho amostral foi realizado pelo método probabilístico aleatório simples, resultando em uma amostra de 100 prontuários. A observação foi utilizada para a coleta de dados e um formulário semiestruturado e anônimo foi utilizado como instrumento. Cada formulário continha dados específicos onde foram categorizadas as variáveis em estudo, como idade, sexo, comorbidades, tempo de sedação, tipo de sedação, sedação utilizada, agitação, confusão, alucinação, sudorese, taquicardia. Resultados: em relação à idade obteve-se uma média de 49 anos, o sexo predominante foi o masculino com 52%, quanto às comorbidades mais frequentes, 20% apresentavam Insuficiência Respiratória Aguda e 16% Insuficiência Renal. O motivo de internação na UTI em maior proporção com 33% foi por dificuldade respiratória e pós-cirúrgicos complicados 32%. Os medicamentos de maior escolha foram midazolam 94%, seguido de fentanil 80%. Quanto ao tempo de sedação dos pacientes, foi encontrada uma média de 1265 horas. As manifestações clínicas mais observadas na amostra correspondem a taquicardia 70%, agitação 52%, confusão e hipertensão 37% e alucinação 24%. Conclusão: as manifestações que ocorreram com maior frequência foram taquicardia, agitação, confusão, hipertensão e, menos frequentemente, alucinação[AU]

Pilot epinephrine dose-finding study to counter epidural-related blood pressure reduction.

OBJECTIVE: An unwanted side effect associated with epidural analgesia is the reduction in blood pressure (BP) due to the sympathetic blockade. This study evaluated the hemodynamic effects of adding different epinephrine concentrations to epidurally injected local anesthetic solution to counteract sympathectomy. We hypothesized that epinephrine could mitigate the decrease in BP possibly caused by the local anesthetic, specifically decreasing the incidence of hypotension. METHODS: Sixty-six patients were enrolled in a randomized, controlled, quadruple-blinded prospective study into three groups: epidural ropivacaine 0.2% without epinephrine (control) or with 2 µg/mL or 5 µg/mL epinephrine. Our primary outcome was the assessment of differences in hypotension between groups, defined as a >20% decrease in hypotension from baseline to the end of the intraoperative period. RESULTS: Forty-seven patients completed the study, and 19 were withdrawn. Fifteen patients were in the control group, while 16 patients received 0.2% ropivacaine +2 µg/mL epinephrine, and 16 received 0.2% ropivacaine +5 µg/mL epinephrine. The overall rate of hypotension was 21.3% (10/47). There were no statistically significant differences in hypotension rates between the control group (33%) and groups receiving either +2 µg/mL (13%, p=0.165) or +5 µg/mL (19%, p=0.353) of epinephrine. In secondary analyses, respiratory rate showed greater decreases in control groups across the perioperative period compared with treatment groups (p=0.016) CONCLUSION: Adding epinephrine to the epidural local anesthetic did not significantly decrease the rate of hypotension. However, epinephrine mitigated decreases in respiratory rate across the perioperative period. Future studies will focus on increasing group size and higher epinephrine concentrations (10 µg/mL). TRIAL REGISTRATION NUMBER: NCT02722746.

Adding Dexmedetomidine to Intra-articular Local Anesthetics Results in Prolonged Analgesia after Knee Arthroscopy: A Systematic Review and Meta-Analysis.

PURPOSE: This systematic review and meta-analysis aims to assess the efficacy and safety of dexmedetomidine as an adjuvant to intra-articular (IA) injections of local anesthetics (LA) in adult patients undergoing knee arthroscopy. METHODS: We searched MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) comparing IA dexmedetomidine plus LA versus LA alone for knee arthroscopy in adults. We used the DerSimonian and Laird random-effects model for all outcomes, and conducted a sensitivity analysis with the leave-one-out method, as well as a subgroup analysis for the type of LA. We used R version 4.1.2 for all statistical analyses. RESULTS: We included 16 RCT encompassing 799 patients, of whom 49.8% received IA dexmedetomidine. In the pooled analysis, time to first analgesia rescue was prolonged in almost 4 hours with the use of dexmedetomidine (MD 229 min; p<0.001). We found statistically significant differences favoring dexmedetomidine in pain scores at rest and movement throughout the first 2, 6, 12 and 24 hours postoperatively (p<0.001). Although the mean difference (MD) ranged from -0.3 to -0.9 cm, corresponding to a 3 to 9% reduction in pain scores, this change is not clinically significant when compared to the minimal clinically important difference (MCID). Additionally, the intervention group showed a statistically significant reduction in cumulative opioid consumption over 24 hours (MD -4.5 mg; p<0.001). However, this reduction did not meet the threshold for the MCID. There was no difference between groups on the incidence of hypotension (p=0.190), bradycardia (p=0.430) and postoperative nausea and vomiting (p=0.550). CONCLUSIONS: Adding dexmedetomidine to LA in IA injections for knee arthroscopy significantly extended analgesia duration. Additionally, it lowered pain scores and opioid use, although these effects did not reach the MCID. Furthermore, this addition did not increase the risk of adverse events.

Impact of different obstetric interventions and types of delivery on breastfeeding: a nationwide cross-sectional survey of Hungarian women.

BACKGROUND: We assessed the effect of different obstetric interventions and types of delivery on breastfeeding. METHODS: A quantitative, cross-sectional study was carried out using an online questionnaire. Data collection was performed in 2021 in Hungary. We included biological mothers who had raised their at least 5-year-old child(ren) at home (N = 2,008). The questionnaire was completed anonymously and voluntarily. In addition to sociodemographic data (age, residence, marital status, education, occupation, income status, number of biological children, and anthropometric questions about the child and the mother), we asked about the interventions used during childbirth, and the different ways of infant feeding used. Statistical analysis was carried out using Microsoft Excel 365 and SPSS 25.0. Descriptive statistics, two-sample t tests, χ2 tests and ANOVA were used to analyse the relationship or differences between the variables (p < 0,05). RESULTS: We found that in deliveries where synthetic oxytocin was used for both induction and acceleration, there was a higher incidence of emergency cesarean section. However, the occurrence of vaginal deliveries was significantly higher in cases where oxytocin administration was solely for the purpose of accelerating labour (p < 0.001).Mothers who received synthetic oxytocin also received analgesics (p < 0.001). Women giving birth naturally who used oxytocin had a lower success of breastfeeding their newborn in the delivery room (p < 0.001). Children of mothers who received obstetric analgesia had a higher rate of complementary formula feeding (p < 0.001). Newborns born naturally had a higher rate of breastfeeding in the delivery room (p < 0.001) and less formula feeding in the hospital (p < 0.001). Infants who were breastfed in the delivery room were breastfed for longer periods (p < 0.001). Exclusive breastfeeding up to six months was longer for infants born naturally (p = 0.005), but there was no difference in the length of breastfeeding (p = 0.081). CONCLUSIONS: Obstetric interventions may increase the need for further interventions and have a negative impact on early or successful breastfeeding. TRIAL REGISTRATION: Not relevant.

Effect of surgery on oxidative stress and endogenous tocopherol concentrations in juvenile female dogs.

BACKGROUND: Surgery such as ovariectomy causes an inflammatory and oxidative stress. This study was designed to evaluate endogenous tocopherol levels in response to surgical oxidative stress induced by abdominal surgery (ovariectomy) in thirty-two juvenile female dogs. The dogs received meloxicam before surgery (0.2 mg/kg SC) and after surgery (0.1 mg/kg OS every 24 h), 0.03 mg/kg of atropine sulfate (IM), and propofol 4 mg/kg intravenously (IV). General anesthesia was maintained with sevoflurane. Physiological, hematological and biochemical parameters, malondialdehyde (MDA) and α-, δ-, γ-tocopherols were evaluated at baseline, 36 and 48 h after surgery. RESULTS: The physiological parameters remained within normal ranges. Blood glucose concentration increased, while the albumin levels decreased after surgery. Rescue analgesia was not required. MDA levels increased above the baseline at 36 and 48 h after surgery (P < 0.001). The α-, δ-, and γ-tocopherol concentrations decreased from baseline at 36 and 48 h after surgery (P < 0.001). CONCLUSIONS: Surgery in juvenile female dogs revealed oxidative, increased MDA concentrations, reduced tocopherol levels, and had a clinically insignificant influence on homeostasis.

Attenuation of acute postoperative pain and opioid requirement with the use of magnesium sulfate in patients undergoing limb amputations.

OBJECTIVE: To compare the effects of magnesium sulphate on the total dose of intravenous morphine consumption postoperatively following limb amputations along with rescue analgesia requirement, pain scores and side effects. METHODS: This prospective, triple-blinded, randomised controlled study was conducted from October 2021 to May 2022 at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised of patients scheduled for limb amputations. They were randomised into 2 equal groups. The anaesthesia protocol was uniform for all patients. Intervention group A was administered 30mg/kg loading dose and 10mg/kg/hr maintenance dose of magnesium sulphate intravenously, while patients in control group B received the same amount of plain isotonic saline. Morphine consumption, including that used for rescue analgesia and patient-controlled analgesia, was measured for 24 hours postoperatively. Numeric rating scale was used for the evaluation of postoperative pain in both groups at 15min, 1h, 2h, at discharge from the post-anaesthesia care unit and at 12h and 24h in the ward. Data was analysed using SPSS 23. RESULTS: Of the 24 patients enrolled, the study was completed by 20(83.33%). There were 10(50%) patients in group A; 8(40%) males and 2(20%) females with mean age 24.8±14.14 years and mean surgery time 130.5±47.86 minutes. There were 10(50%) patients in group B; 8(40%) males and 2(20%) females with mean age 23.2±7.4 years and mean surgery time 117±23.85 minutes (p>0.05). Total morphine used over 24 hours in group A was 16±3.1 mg compared to 29.6±11.2 mg in group B (p<0.05). The time for first use of patient-controlled analgesia after arriving in the postanaesthesia care unit was significantly delayed in group A (72.2±24.95 minutes) compared to that in group B (25±26.68 minutes) (p<0.05). Pain scores were significantly higher in the group B at 15min compared to group A (p<0.05), but not at the rest of the time points (p>0.05). CONCLUSIONS: Intravenous magnesium sulphate proved to be effective in lowering postoperative opioid requirement following limb amputations.

Epidural Block in a Patient With Melkersson-Rosenthal Syndrome: A Case Report.

This case report describes the first known application of an epidural block for labor analgesia in a patient with Melkersson-Rosenthal syndrome (MRS), a rare disorder that may present sudden and threatening airway complications. A tailored epidural protocol effectively mitigated symptom exacerbation, facilitating a complication-free vaginal delivery. This report not only enriches the sparse literature on anesthesia in patients with MRS but also provides a crucial review of perioperative considerations for administering either general or regional anesthesia in similar cases.

Lateness of Acetaminophen and Non-steroidal Anti-inflammatory Drug Administrations in a Retrospective Cohort of Medication Administration Records Among Patients After Cesarean Delivery.

INTRODUCTION: In an earlier study of patients after cesarean delivery, the concurrent versus alternating administration of acetaminophen and non-steroidal anti-inflammatory drugs was associated with a substantial reduction in total postoperative opioid use. This likely pharmacodynamic effect may differ if the times when nurses administer acetaminophen and non-steroidal anti-inflammatory drugs often differ substantively from when they are due. We examined the "lateness" of analgesic dose administration times, the positive difference if administered late, and the negative value if early. METHODS: The retrospective cohort study used all 67,900 medication administration records for scheduled (i.e., not "as needed") acetaminophen, ibuprofen, and ketorolac among all 3,163 cesarean delivery cases at the University of Iowa between January 2021 and December 2023. Barcode scanning at the patient's bedside was used right before each medication administration. RESULTS: There were 95% of doses administered over a 4.8-hour window, from 108 minutes early (97.5% one-sided upper confidence limit 105 minutes early) to 181 minutes late (97.5% one-sided lower limit 179 minutes late). Fewer than half of doses (46%, P <0.0001) were administered ±30 minutes of the due time. The intraclass correlation coefficient was approximately 0.11, showing that there were small systematic differences among patients. There likewise were small to no systematic differences in lateness based on concurrent administrations of acetaminophen and ibuprofen or ketorolac, time of the day that medications were due, weekday, year, or number of medications to be administered among all such patients within 15 minutes. DISCUSSION: Other hospitals should check the lateness of medication administration when that would change their ability to perform or apply the results of analgesic clinical trials (e.g., simultaneous versus alternating administration).

Effect of pericapsular nerve group block and suprainguinal fascia iliaca block on postoperative analgesia and stress response in elderly patients undergoing hip arthroplasty: a prospective randomized controlled double-blind trial.

BACKGROUND: As a novel regional analgesic technique, ultrasound-guided pericapsular nerve group (PENG) block has some potential advantages, and we designed a randomized clinical trial (RCT) to investigate whether the ultrasound-guided PENG block combined with general anesthesia can better reduce stress response, maintain intraoperative hemodynamic stability, and reduce postoperative analgesia in elderly hip arthroplasty compared with ultrasound-guided suprainguinal fascia iliaca block (SIFIB) combined with general anesthesia. METHODS: Seventy-four subjects were enrolled over an 8-month period (20 April 2023 to 31 December 2023). All patients were divided into the test group (group P) and the control group (group S) using the envelope as the randomization method. The test group was treated with preoperative ultrasound-guided PENG block analgesia combined with general anesthesia and the control group was treated with preoperative ultrasound-guided SIFIB analgesia combined with general anesthesia. The primary outcome selected was the patient Visual Analogue Scale (VAS) score at 12 h postoperatively. RESULTS: After generalized estimating equations (GEE) analysis, there was a statistically significant difference in the main effect of postoperative VAS score in group P compared with group S (P = 0.009), the time effect of VAS score in each group was significantly different (P < 0.001), and there was no statistically significant difference in the group-time interaction effect (P = 0.069). There was no statistically significant difference in the main effect of intraoperative mean arterial pressure (MAP) change (P = 0.911), there were statistically significant differences in the time effect of MAP in each group (P < 0.001), and there were statistically significant differences in the interaction effect (P < 0.001). CONCLUSIONS: In summary, we can conclude that in elderly patients undergoing hip fracture surgery, postoperative analgesia is more pronounced, intraoperative hemodynamic parameters are more stable, and intraoperative stress is less induced in patients receiving SIFIB than in patients receiving PENG block.

Effects of different doses of dexmedetomidine combined with sufentanil in intravenous controlled analgesia after Salter osteotomy in children.

Background: This study aimed to investigate the effect of different doses of dexmedetomidine combined with sufentanil on postoperative analgesia in developmental hip dislocation in children after Salter osteotomy. Methods: The clinical data of 98 children with developmental hip dislocation, who underwent Salter osteotomy in our center between January 2020 and February 2023, were selected. The children were randomly divided into four groups based on the application of patient-controlled intravenous analgesia (sufentanil + granisetron ± dexmedetomidine). All children received 1 µg/kg/day of sufentanil and 3 mg of granisetron. Group A did not receive dexmedetomidine, and Groups B, C, and D received 0.5, 0.75, and 1.0 µg/kg/day of dexmedetomidine, respectively. The pain indicators and immune factor levels of children in each group were compared. Results: The heart rate (HR) and respiratory rate (RR) 2 h after operation in Groups C and D were significantly lower than those in Groups A and B (P < 0.05). The pain scores decreased over time after treatment in all groups. When compared at the same time point, children in Group D had the lowest pain scores, which were significantly lower than the other three groups (P < 0.05). The total consumption of sufentanil in Groups C and D was significantly lower than that in Group A (P < 0.05). On the first day after surgery, the children in Group D had lower levels of serum adrenocorticotropic hormone, interleukin-6, and corticosterone than those in Group A (P < 0.05). Conclusion: Administration of 1.0 µg/kg/day of dexmedetomidine combined with sufentanil in intravenous controlled analgesia after Salter osteotomy for developmental hip dislocation in children has a better analgesic effect, less consumption of sufentanil, and low incidence of opioid adverse reactions.

Acute Pain Management in a Multi-site Trauma Patient.

Pain management is often difficult in the setting of multi-site trauma such as that caused by motor vehicle accidents (MVA), which is especially compounded in the setting of polysubstance abuse. This often results in patients with poor pain tolerance requiring escalating doses of opioid therapy, which creates a vicious cycle. The use of peripheral nerve blocks (PNB) has been shown to decrease overall opioid consumption and can be used effectively to manage postoperative pain in this patient population. Our case report aims to highlight the importance of PNBs as part of a multimodal approach to pain management in patients with polytrauma in the setting of polysubstance abuse.

Plasma concentrations of buprenorphine administered via matrix-type transdermal patches applied at three different anatomical locations in healthy adult horses.

Background: Anatomical location-dependent differences in transdermal opioid penetration are well described in human patients. Although this has been investigated in horses with fentanyl, there is no literature available on location-dependent plasma buprenorphine concentrations when administered as a transdermal matrix-type patch. Objective: This study aims to compare the plasma concentrations achieved from the matrix-type transdermal buprenorphine patches placed at different anatomical sites (metacarpus, gaskin, and ventral tail base) in healthy adult horses. Study design: This is a randomized experimental study with a Latin square design. Methods: Six adult horses were given each of three treatments with a minimum 10-day washout period. For each treatment, two 20 µg h-1 matrix-type buprenorphine patches were applied to the ventral aspect of the tail base (TailTDP), metacarpus region (MetacarpusTDP), or gaskin region (GaskinTDP). Whole blood samples (for determination of buprenorphine concentration) and physiological variables were collected before (0 h) and at 0.5, 2, 4, 6, 8, 10, 12, 16, 24, 32, 48, 56, 72, 96 and 120 h after patches were applied. The patches were removed 96 h following placement and were analyzed for residual buprenorphine content. Buprenorphine concentrations were measured in plasma by LC-MS/MS. A mixed-effects model was used to analyze the physiological variables. Results: Between the three treatment groups, there was no change in physiological variables across timepoints as compared to baseline and when compared to each other in a single horse and between horses (p > 0.3). When comparing all three locations, the buprenorphine uptake was observed to be more consistent with respect to measurable plasma concentrations >0.1 ng ml-1 when applied to the ventral aspect of the tail base. In the TailTDP group, the mean plasma buprenorphine concentrations were >0.1 ng ml-1 from 2 to 32 h. The highest group mean was 0.25 ng ml-1 noted at 4 h. Conclusions: The metacarpal and gaskin regions presented more erratic and inconsistent buprenorphine uptake and plasma concentrations as compared to the ventral aspect of the tail base. Further research must be directed at investigating the optimal dose, achievable duration of analgesia, change in measurable plasma concentrations, and behavioral and systemic effects.

Use of subcutaneous maropitant at two dosages for pain management in domestic rabbits (Oryctolagus cuniculus) undergoing elective ovariohysterectomy or orchiectomy.

OBJECTIVE: To describe the effect of two doses of maropitant on pain scores, food intake, and fecal output in domestic rabbits (Oryctolagus cuniculus) undergoing elective ovariohysterectomy or orchiectomy. ANIMALS: 26 (11 female, 15 male) rabbits from three institutions. PROCEDURES: Rabbits were randomly assigned to one of three treatment groups: low-dose maropitant (LDM; 2 mg/kg SC once; n=8), moderate-dose maropitant (MDM; 4 mg/kg SC once; n=10), and control (saline equivalent to 4 mg/kg maropitant SC once; n=8), administered prior to surgery. Following surgery, all rabbits were provided buprenorphine (0.06 mg/kg q 8 hours) and meloxicam (1 mg/kg q 24 hours) intramuscularly. Rabbits were monitored using video surveillance postoperatively until 24 hours after surgery or discharge from the hospital, whichever came first. Pain scores were assessed by three blinded observers, and results were grouped into early (0-4 hours), mid (5-8 hours), and late (12-24 hours) time frames. Food intake and fecal output were compared between groups. Statistical analysis was performed using Chi square, Fisher's exact tests, and a mixed model approach. RESULTS: There were no adverse effects with maropitant administration. Rabbits that received MDM had significantly lower pain scores in the mid-time frame and behavior scores in the late-time frame compared to controls. Male rabbits consumed more food than females and rabbits hospitalized longer than 12 hours consumed more food than those that were discharged prior. No significant differences were detected in facial grimace scale scores, food intake, or fecal production among treatment groups. CONCLUSIONS AND CLINICAL RELEVANCE: Moderate dose maropitant decreased pain related behaviors in the mid-time frame and behavior scores in the late-time frame after surgery. Further studies are necessary to better characterize the potential use of maropitant in postoperative analgesia.

Effects of perioperative dexmedetomidine on delayed graft function following renal transplant: a systematic review and meta-analysis.

BACKGROUND: Dexmedetomidine, a highly selective alpha-2 adrenoceptor agonist with sedative and analgesic effects, has been suggested in recent studies to possess renoprotective properties. Dexmedetomidine may reduce the incidence of delayed graft function and contribute to effective pain control post-renal transplantation. The primary objective of this systematic review was to assess whether dexmedetomidine decreases the occurrence of delayed graft function in renal transplant patients. METHODS: Databases including MEDLINE, EMBASE, and CENTRAL were comprehensively searched from their inception until March 2023. The inclusion criteria covered all Randomized Clinical Trials (RCTs) and observational studies comparing dexmedetomidine to control in adult patients undergoing renal transplant surgery. Exclusions comprised case series and case reports. RESULTS: Ten RCTs involving a total of 1,358 patients met the eligibility criteria for data synthesis. Compared to the control group, the dexmedetomidine group demonstrated a significantly lower incidence of delayed graft function (OR = 0.71, 95% CI 0.52-0.97, p = 0.03, GRADE: Very low, I2 = 0%). Dexmedetomidine also significantly prolonged time to initiation of rescue analgesia (MD = 6.73, 95% CI 2.32-11.14, p = 0.003, GRADE: Very low, I2 = 93%) and reduced overall morphine consumption after renal transplant (MD = -5.43, 95% CI -7.95 to -2.91, p < 0.0001, GRADE: Very low, I2 = 0%). The dexmedetomidine group exhibited a significant decrease in heart rate (MD = -8.15, 95% CI -11.45 to -4.86, p < 0.00001, GRADE: Very low, I2 = 84%) and mean arterial pressure compared to the control group (MD = -6.66, 95% CI -11.27 to -2.04, p = 0.005, GRADE: Very low, I2 = 87%). CONCLUSIONS: This meta-analysis suggests that dexmedetomidine may potentially reduce the incidence of delayed graft function and offers a superior analgesia profile as compared to control in adults undergoing renal transplants. However, the high degree of heterogeneity and inadequate sample size underscore the need for future adequately powered trials to confirm these findings.

Efficacy and Safety of Intrathecal Morphine for Cesarean Delivery: A Narrative Review.

PURPOSE OF REVIEW: Pain management is a critical aspect of care during and following a cesarean delivery. Without proper control of pain, individuals can experience poor mobility, increased thromboembolic events, and difficulty caring for the neonate in the postpartum period. There have been multiple methods for pain management for cesarean delivery and intrathecal morphine (ITM) has emerged as a prominent option for post-operative analgesia due to its efficacy, safety, and potential benefits over other treatments. This review analyzes data on efficacy, side effects, and safety of ITM and the pain control alternatives. RECENT FINDINGS: A comprehensive literature review was conducted to compare ITM with other analgesic techniques in post-cesarean patients. ITM was found to be as effective or better than other analgesic options, including bilateral quadratus lumborum block (QLB), opioid-free epidural analgesia (CSEA-EDA), and intravenous fentanyl. One study found that both ITM and oral analgesia were effective in pain control and that ITM caused fewer breakthrough pain events but had a longer duration and a greater rate of side effects than oral opioid analgesia. Commonly observed side effects of intrathecal opioids include nausea, vomiting, pruritus, and urinary retention, and it is thought that the adverse effects from intrathecal administration of opioids are short-lived. ITM may provide a decreased risk of DVT and coagulation by decreasing lower extremity weakness and numbness, thereby decreasing recovery time and increasing mobility. ITM is a safe and effective option for post-cesarean analgesia, with comparable pain relief to alternative forms of pain control, and side effects that are generally manageable. Further research is warranted to explore beneficial combinations with other methods of pain management and optimal dosing strategies.

Assessment of catheter position using chest CT in adults undergoing erector spinae plane analgesia for rib fractures: a retrospective cohort study.

BACKGROUND: Continuous erector spinae plane (ESP) analgesia is a common adjuvant for patients with traumatic rib fracture pain and success relies on the ESP catheter remaining within the correct fascial plane for the duration of its placement. However, knowledge on postplacement position of indwelling ESP catheters is largely absent. We hypothesized that migration of over-the-needle ESP catheters was common and detectable with coincidental postprocedure CT. METHODS: In this single-center retrospective cohort study, adults admitted to the surgical intensive care unit for traumatic rib fractures between January 2020 and July 2022 were screened. Those receiving continuous ESP analgesia via indwelling catheter and undergoing subsequent chest CT were included. The primary outcome was the proportion of catheters that migrated outside the ESP. The secondary outcome was the distance between the catheter tip and the nearest transverse process (TP) or fascial plane. RESULTS: 160 medical records were screened for eligibility and 15 patients (18 catheters) met the inclusion criteria. 16 of 18 catheters reviewed were found outside the ESP. Furthermore, catheter position was reported as intramuscular in 14 catheters and subcutaneous in 4 catheters. The median distance between catheter tip and the nearest TP (or the ESP) was 23.20 mm sagittally and 25.05 mm axially. CONCLUSIONS: Most ESP catheters were found superficial to the fascial plane in the days following their placement. The median distance between the catheter and the ESP is between 23 and 25 mm. Prospective studies should address catheter migration concerns and propose solutions to this common issue.

Effects of a Preoperative Patient-Controlled Analgesia Education Program Using Smart Learning in Laparoscopic Cholecystectomy Patients.

BACKGROUND: Patients undergoing laparoscopic cholecystectomy develop severe postoperative pain, and this acute pain often becomes chronic. OBJECTIVES: This study determines the effects of preoperative education on patient-controlled analgesia (PCA) through smart learning in patients using PCA after undergoing laparoscopic cholecystectomies. DESIGN: We conducted a quasi-experimental study with a nonequivalent control group pretest-posttest design. PARTICIPANTS: A total of 60 adult patients aged 20-65 years, admitted for laparoscopic cholecystectomy at a hospital in Korea, participated in a smart learning training program. METHODS: The concept of smart learning, which integrates learning content and solutions with the fourth industrial revolution using mobile devices such as smartphones and media tablets was applied in this study. This smart learning training program comprised three phases: (1) prebriefing, where patients accessed PCA knowledge via a program created by researchers and accessible using a mobile web device (e.g., smartphone or an iPad), with training covering pain characteristics, PCA effects, precautions, and usage methods; (2) simulation, where patients learned using PCA with a machine; (3) debriefing, where patients reviewed their knowledge and skills. RESULTS: Comparing the pain between the experimental and control groups, the pain decreased significantly in both the experimental (Z = -4.40, p < .001) and control groups (Z = -4.41, p < .001), with no significant difference between groups (Z = -1.00, p = .319). Preoperative knowledge significantly increased in both the experimental (Z = -4.74, p < .001) and control groups (Z = -3.55, p < .001), with a significant difference between groups (Z = -6.05, p < .001). Total satisfaction with pain control was higher in the experimental group than in the control group. CONCLUSIONS: A structured educational program on PCA use is an effective nursing intervention. PCA educational programs using smart learning could help patients undergoing laparoscopic cholecystectomy understand postoperative pain, promote efficient PCA use, and enhance their satisfaction with pain control.

Anesthetic management with labor epidural analgesia of the parturient with severe factor VII deficiency: a case report.

BACKGROUND: Factor VII deficiency is considered a contraindication to neuraxial anesthesia due to the risk of an epidural hematoma. CASE REPORT: A 32 year old G1P0 parturient with severe factor VII deficiency presented for an anesthesiology consultation at 32 weeks gestation. Initial coagulation studies were significant for an elevated INR (2.0) and a low factor VII level of 6%. After interdisciplinary discussion, it was decided that neuraxial analgesia could be offered if her coagulation studies corrected after administration of recombinant activated factor VII (rFVIIa). The patient presented at 36 weeks gestation for a rFVIIa challenge. She received 22 mcg/kg rFVIIa and coagulation studies were analyzed 20 minutes later which showed complete correction of the coagulopathy. The patient presented to the hospital at 39 weeks and 3 days for delivery, received 2 mg rFVIIa and 20 minutes later, successfully received an epidural catheter. Her INR was monitored every 3 hours during her labor course and rFVIIa was given if the INR was 1.3 or greater. She required three additional doses over 22 hours. No bleeding or thrombotic events occurred, and the patient was discharged home without complications. CONCLUSION: This case highlights the safe management of an epidural catheter in a parturient with severe factor VII deficiency.