RESUMO
BACKGROUND: Optimal postoperative analgesia is a challenge for the anaesthesiologist, with the ideal combination of methods, drugs, doses and timing of administration still the subject of research. The COX-2 inhibitors are a class of NSAIDs that may provide useful perioperative analgesia but the optimal timing of administration has not been elucidated. OBJECTIVE: We hypothesised that etoricoxib given 1âh before total knee arthroplasty under spinal anaesthesia will decrease the cumulative dose of intravenous and subcutaneous morphine required to maintain pain intensity of 3 or less on a 10-point numerical rating scale (NRS) during the first postoperative 48âh compared with the same dose of etoricoxib given after surgery. DESIGN: Randomised, double-blind, placebo-controlled trial. SETTING: University hospital, between January and September, 2014. PATIENTS: Overall, 165 patients scheduled for total knee arthroplasty under spinal anaesthesia. INTERVENTIONS: The patients were randomised into one of three groups: the ETORICOX-PREOP group received etoricoxib 120âmg orally 1âh before surgery, one placebo pill at the end of surgery and a further 120âmg etoricoxib after 24âh; the ETORICOX-POSTOP group received one placebo pill 1âh before surgery and etoricoxib 120âmg at the end of surgery and after 24âh. The PLACEBO group received one placebo pill 1âh before surgery, one at end of surgery and a third after 24âh. MAIN OUTCOME MEASURES: The primary outcome measure was the cumulative dose of intravenous and subcutaneous morphine required during the first postoperative 48âh to maintain a 10-point numerical pain rating scale value of 3 or less. Secondary outcomes measures were duration of analgesia from initiation of spinal anaesthesia until the first analgesic requirement and the side-effects of the treatment. RESULTS: The quantity of morphine over the first postoperative 48âh required by the ETORICOX-PREOP group (44â±â16âmg) and the ETORICOX-POSTOP group (52â±â23âmg) were both significantly less than the PLACEBO group (71â±â20âmg) (Pâ=â0.001), demonstrating a morphine-sparing effect of etoricoxib of the order of 30%; the difference between the PRE vs. POST groups was statistically significant (Pâ=â0.02), favouring a preemptive analgesic effect. Also, there was evidence of a longer time to first analgesia compared with PLACEBO in the PREOP group (Pâ=â0.02) but no significant difference between PREOP and POSTOP groups (Pâ=â0.30). There was no difference in side-effects among the three study groups and there were no serious adverse effects of etoricoxib. CONCLUSION: Preemptive administration of etoricoxib 120âmg orally in patients undergoing total knee arthroplasty under spinal anaesthesia is superior to postoperative administration of the same dose in terms of its morphine-sparing effect during the first postoperative 48âh, but not in prolonging the time to first analgesia, and is associated with a similar incidence of side-effects. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT 02534610.
Assuntos
Raquianestesia/métodos , Artroplastia do Joelho/efeitos adversos , Inibidores de Ciclo-Oxigenase 2/administração & dosagem , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Piridinas/administração & dosagem , Sulfonas/administração & dosagem , Idoso , Analgésicos Opioides/administração & dosagem , Método Duplo-Cego , Etoricoxib , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/prevenção & controleRESUMO
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are major orthopedic surgery models, addressing mainly ageing populations with multiple comorbidities and treatments, ASA II-IV, which may complicate the perioperative period. Therefore effective management of postoperative pain should allow rapid mobilization of the patient with shortening of hospitalization and social reintegration. In our review we propose an evaluation of the main analgesics models used today in the postoperative period. Their comparative analysis shows the benefits and side effects of each of these methods and guides us to how to use evidence-based medicine in our daily practice.
RESUMO
ABSTRACT: Venous thromboembolism (VTE) is an important complication of major orthopedic surgery (total hip arthroplasty-THA, total knee arthroplasty-TKA, hip fracture surgery-FHS) and is associated with significant morbidity and mortality. Despite this, not all patients receive an appropriate prophylaxis, often due to a disproportionate fear of bleeding complications. A challenge in the management of VTE prophylaxis is to balance the benefits of the treatment with the risk of bleeding. In this article, we review the latest guidelines recommendations regarding prevention of postoperative VTE in patients undergoing orthopedic surgery.