[Quality of postoperative analgesia protocols in a local hospital]. / Evaluación de la aplicación de protocolos de analgesia postoperatoria en un hospital comarcal: estudio de calidad.

OBJECTIVES: To demonstrate that the introduction of a nursing based Acute Pain Service (APS) leads to better postoperative pain management and a decrease in treatment-related adverse events. To assess the quality criteria of postoperative pain control and discuss their compliance. MATERIALS AND METHODS: A total of 116 major elective surgeries were assessed between November and December 2010 and compared to those collected between November and December 2007 before the introduction of the APS. The following variables were studied: sociodemographic data, type of surgery and postoperative analgesia, pain ratings (numeric verbal scale- NVS) per nursing shift (48 hours), compliance of quality criteria in pain management, and a patient satisfaction survey. RESULTS AND CONCLUSIONS: Despite there being a higher number of surgeries related to expected moderate-intense pain, better scores in pain ratings were obtained both at rest (86.1% ± 11.2 vs 50.7% ± 12.1 NVS ≤ 3, p=.0001) and during activity (73.9% ± 10.8 vs 50.1% ± 12.1 NVS ≤ 5, p=.0026) in surgical wards, but treatment-related side effects did not decrease with the analgesics and there was no increase treatment-related patient satisfaction. The data analysis showed that there is still a deficiency in the recording of the pain scores by nursing shift (70 ± 6.1 vs 40 ± 11.9, p=.0002).

[Epidural blood patch to treat severe postdural puncture headache after ambulatorysurgery]. / Parche hemático epidural en el tratamiento de cefalea postpunción dural grave en cirugía mayor ambulatoria.

We report a case of postdural puncture headache (PDPH) after outpatient hysteroscopy under spinal anesthesia in which a 25-gauge Whitacre needle was used. Symptoms of PDPH appeared 6 hours after surgery. The headache improved with oral caffein and intravenous corticosteroids and the patient was discharged after 24 hours. Later, she was attended twice in the emergency departments of 2 hospitals, where she received conventional treatment (analgesics and corticosteroids). Eleven days after the surgical procedure, an epidural blood patch was performed. Within 12 hours the incapacitating symptoms had improved markedly and resolution was complete 2 months after surgery. PDPH worthy of blood patch treatment is a rare complication of spinal anesthesia with pencil-point needles. Clear diagnostic protocols are required if satisfactory treatment is not to be delayed and unnecessary suffering is to be prevented.

Parche hemático epidural en el tratamiento de cefalea postpunción dural grave en cirugía mayor ambulatoria / Epidural blood patch to treat severe postdural puncture headache after ambulatory surgery

Presentamos un caso de cefalea postpunción duralgrave tras realización de histeroscopia quirúrgica ambulatoriacon anestesia subaracnoidea con aguja de puntaWhitacre 25G, que presentó cuadro compatible conCPPD a las 6 horas de la cirugía. La paciente fue tratadacon cafeína oral y corticoides intravenosos con mejoríadel cuadro, por lo que fue dada de alta a las 24 horas.Reingresó en dos ocasiones en Servicios de Urgencias de2 hospitales recibiendo tratamiento convencional (analgésicos,corticoides). Once días después se realizó unparche hemático epidural con franca mejoría del cuadroinvalidante en 12 horas y resolución completa en 2meses. La cefalea postpunción dural subsidiaria de parchehemático es una complicación excepcional tras realizaciónde anestesia subaracnoidea con agujas de puntade lápiz en cirugía ambulatoria. El tratamiento satisfactoriorequiere protocolos diagnósticos claros para nodemorar el tratamiento y evitar sufrimientos innecesarios(AU)

We report a case of postdural puncture headache(PDPH) after outpatient hysteroscopy under spinalanesthesia in which a 25-gauge Whitacre needle was used.Symptoms of PDPH appeared 6 hours after surgery. Theheadache improved with oral caffein and intravenouscorticosteroids and the patient was discharged after 24hours. Later, she was attended twice in the emergencydepartments of 2 hospitals, where she received conventionaltreatment (analgesics and corticosteroids). Eleven days afterthe surgical procedure, an epidural blood patch wasperformed. Within 12 hours the incapacitating symptomshad improved markedly and resolution was complete 2months after surgery. PDPH worthy of blood patchtreatment is a rare complication of spinal anesthesia withpencil-point needles. Clear diagnostic protocols are requiredif satisfactory treatment is not to be delayed andunnecessary suffering is to be prevented(AU)

[Premedication with intraoperative clonidine and low-dose ketamine in outpatient laparoscopic cholecystectomy]. / Premedicación con clonidina y ketamina intraoperatoria a bajas dosis en la colecistectomía laparoscópica ambulatoria.

OBJECTIVE: To determine the efficacy of premedication with intraoperative clonidine in association with low-dose ketamine to reduce the need for postoperative opiate analgesia in outpatient laparoscopic cholecystectomy. PATIENTS AND METHODS: We performed a prospective study of patients undergoing outpatient laparoscopic cholecystectomy between November 2005 and November 2006. The patients were distributed randomly in 2 groups: patients in the clonidine-ketamine group received clonidine (0.15 mg orally 60 minutes before surgery) and ketamine (20-mg intravenous bolus followed by intraoperative perfusion of 20 mg h(-1)); patients in the control group did not receive this medication. Pain assessed on a verbal numerical scale, number of times rescue analgesia was required to achieve a value below 3, and adverse effects of the medication were recorded in the postoperative period. RESULTS: Thirty-one patients (16 in the clonidine-ketamine group and 15 in the control group) were enrolled. Rescue analgesia was required on 2 occasions by 25% of patients in the clonidine-ketamine group and on 2 or 3 occasions by 533% of patients in the control group. Adverse effects were reported by 87.5% of patients in the clonidine-ketamine group (mainly visual disturbances, sedation, and nausea) and by 46.7% in the control group. This difference was significant during the patients' stay in the postanesthesia recovery unit. CONCLUSIONS: Patients receiving clonidine and ketamine required less additional opiate analgesia to achieve mild pain values (<3 on the numerical verbal scale) but suffered more adverse effects during their stay in the postanesthesia recovery unit. Discharge was not delayed, however.

[Accidental dural puncture during epidural injection of corticosteroids: a different approach?]. / Punción dural accidental en la infiltración epidural con corticoide. Un abordaje diferente?

We report 6 cases diagnosed with accidental dural puncture after epidural injection of corticosteroids for low back pain. All the patients reported postdural puncture headache during their stay in the postanesthetic recovery unit. For 3 patients, pain resolved with treatment given in the recovery unit. Two other patients also required mild analgesics for 1 week. In the last patient, a blood patch was used to treat incapacitating headache 22 days after the epidural procedure and mild analgesics were needed for 4 more weeks. It is important to establish a protocol for treating postdural puncture headache in pain clinics to facilitate decision making. Good physician-patient communication is necessary to avoid refusals for permission for other epidural techniques and to facilitate management of symptoms.

Punción dural accidental en la infiltración epidural con corticoide. ¿Un abordaje diferente? / Accidental dural puncture during epidural injection of corticosteroids: a different approach?

Presentamos los 6 casos de pacientes en los que sediagnosticó una punción dural accidental tras infiltraciónepidural con corticoide por lumbociatalgia. Todos refirieroncefalea postpunción dural durante su permanenciaen la Unidad de Recuperación Postanestésica. En 3 deellos la cefalea remitió con los tratamientos recibidos enesta unidad, dos pacientes necesitaron además tratamientocon analgésicos menores durante 1 semana y en el últimopaciente se realizó un parche hemático por cefaleainvalidante a los 22 días de la infiltración y tratamientocon analgésicos menores durante 4 semanas más.Es importante disponer de un protocolo de tratamientode Cefalea Postpunción Dural en los pacientes entratamiento en las Unidades de Dolor para facilitar latoma de decisiones, y es fundamental un buen entendimientomédico-paciente para evitar negativas ante nuevastécnicas epidurales y facilitar el abordaje del cuadro

We report 6 cases diagnosed with accidental duralpuncture after epidural injection of corticosteroids forlow back pain. All the patients reported postdural punctureheadache during their stay in the postanestheticrecovery unit. For 3 patients, pain resolved with treatmentgiven in the recovery unit. Two other patients alsorequired mild analgesics for 1 week. In the last patient,a blood patch was used to treat incapacitating headache22 days after the epidural procedure and mild analgesicswere needed for 4 more weeks.It is important to establish a protocol for treating postduralpuncture headache in pain clinics to facilitate decisionmaking. Good physician-patient communication isnecessary to avoid refusals for permission for other epiduraltechniques and to facilitate management of symptoms