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Purpose: Magnesium sulfate (MgSO4) may enhance the effects of local anesthetics when used as an adjuvant in peripheral nerve blocks. Our objective was to evaluate efficiency and safety of utilizing MgSO4 alongside levobupivacaine in bilateral ultrasound-guided transversus abdominis plane (US-TAP) block for postoperative pain in pediatric cancer patients who underwent abdominal surgery. Methodology: A randomized double-blinded controlled trial at South Egypt Cancer Institute, Assiut University, Assiut, Egypt, included that 40 pediatric patients with Wilms' tumor or neuroblastoma were randomly allocated to get bilateral (US-TAP) block and divided into two groups; M group: received US-TAP with 0.6 mL/kg levobupivacaine 0.25% + 2 mg/kg MgSO4 and C group: received with 0.6 mL/kg levobupivacaine 0.25% only. FLACC scores (Face, Leg, Activity, Cry, Consolability) were used to evaluate post-operative pain, first analgesic request, total analgesic consumption, adverse effects, as well as hemodynamics were monitored for 24 h and recorded at time points (2, 4, 6, 8, 12, 18, and 24h). Parent's satisfaction at discharge, also, was evaluated. Results: FLACC score in M group was significantly lower than in C group from 4 h to 24 h with the first analgesic request being longer (15.95 ± 1.99 vs 7.70 ± 0.80 (h); p < 0.001) and lower total analgesic consumption (231.75 ± 36.57 vs 576.00 ± 170.71 (mg); p < 0.001) when comparing M group to C group, respectively. Both groups had insignificant differences regarding hemodynamics, parent satisfaction, postoperative agitation, and side effects except vomiting occurred in two patients in the C group and one patient in the M group. Conclusion: We conclude that adding magnesium sulphate as an adjuvant to local anaesthetic in US-TAP block for pain management in pediatric abdominal cancer surgeries resulted in better and longer analgesia, with less consumption of rescue analgesics with no serious side effects.
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Purpose: A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy. Methods: Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T9 (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours. Results: A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points. Conclusion: Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.
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Epidural analgesia is often considered cornerstone in multimodal analgesia when used in major surgeries. However, its role in managing acute postoperative pain in elderly patients is debatable because of its known potential complications. Furthermore, postoperative pain in elderly patients is under-treated because of complex comorbidities, and they are more prone to adverse events related to pain therapies. All systemic analgesic drugs have pharmacological limitations and precautions in elderly people. Recent meta-analyses showed that epidural analgesia provided better postoperative pain control compared to intravenous opioids. Interestingly, peripheral nerve blocks had no superior control of pain over epidural analgesia. In addition, epidural analgesia has shown to positively affect perioperative morbidities and mortalities, and reduce opioid-related side effects because of its non-analgesic effects on each organ system. When tailored in a specific multimodal approach, it shortens the intensive care and hospital stays. In conclusion, if complications are identified and treated early, and contraindications are ruled out, epidural analgesia can achieve sufficient postoperative pain management with insignificant adverse events in this population.
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BACKGROUND: An impaired immune system in the perioperative period has important clinical implications in patients with cancer. Despite the immunosuppressive properties of opioid therapy, it is still commonly utilized in the intrathecal or epidural space for the treatment of postoperative pain. Also, intrathecal dexmedetomidine has extended analgesic efficacy in postoperative pain; it can significantly affect immune function in perioperative patients. OBJECTIVE: To investigate the effect of intrathecal morphine, dexmedetomidine, or both in combination with bupivacaine on cellular immunity and cytokine production in cancer surgical patients. STUDY DESIGN: A prospective randomized clinical study. SETTING: South Egypt Cancer Institute, Assiut University. METHODS: Ninety patients were randomly assigned to receive intrathecal morphine 0.5 mg (Group M, n = 30), dexmedetomidine 0.5 µg/kg (Group D, n = 30) or morphine 0.5 mg with dexmedetomidine 0.5 µg/kg (Group MD n = 30); 2 mL bupivacaine 0.5% was added to injected drugs in all groups. Blood samples were collected preoperative (T0), immediate postoperative (T1), 4 hours postoperative (T2), and 24 hours postoperative (T3) for measurement of CD3, CD4, CD4/CD8 and CD16+56(NK), interleukin(IL)-1beta (IL-1beta), IL-6, IL-10 and tumor necrosis factor alpha (TNF-alpha). RESULTS: A significant reduction in cellular immunity (CD3, CD4, CD8, CD4/CD8, CD 16+56) was noticed in the 24-hour postoperative period in all 3 studied groups, with a marked reduction in Group M in comparison to Group MD and Group D. Regarding inflammatory mediators, IL-10 and IL-1beta showed significant reduction in Group M in the first 24-hour postoperative period in comparison to Group MD and Group D, while IL-6 was significantly reduced in Group MD and Group D in comparison to Group M in the same period. TNF-alpha was significantly increased postoperative at T1 and T2 in the 3 studied groups, then at T3 it decreased without a statistically significant difference with the preoperative level. LIMITATIONS: Our study has some limitations, such as the short period of follow-up and lack of postoperative clinical follow-up of patients to discover the association between immunity and patient outcomes. CONCLUSION: Intrathecal dexmedetomidine has the least immunosuppressive effect than morphine and morphine-dexmedetomidine, in combination with bupivacaine.
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Neoplasias Abdominales , Dexmedetomidina , Humanos , Bupivacaína/uso terapéutico , Morfina/uso terapéutico , Dexmedetomidina/uso terapéutico , Interleucina-10/uso terapéutico , Estudios Prospectivos , Factor de Necrosis Tumoral alfa/uso terapéutico , Interleucina-6/uso terapéutico , Método Doble Ciego , Dolor Postoperatorio/tratamiento farmacológico , Analgésicos Opioides/uso terapéutico , Neoplasias Abdominales/cirugía , Anestésicos Locales/uso terapéuticoRESUMEN
Purpose: Breast surgeons seek simple, safe, effective, and novel regional anesthesia techniques for postoperative analgesia. Erector spinae plane (ESP) block is a new ultrasound-guided technique. We aimed to explore the analgesic effect of adding ketamine and magnesium sulfate as adjuvants to levobupivacaine in ESP. Patients and Methods: Sixty female patients (aged 18-60 years) with breast cancer, weighing 50-90 kg who were scheduled for modified radical mastectomy (MRM) were randomly allocated into three groups (20 patients each) to receive an ESP block with 20 mL 0.25% levobupivacaine with adjuvants according to the following groups: group C: levobupivacaine; group K: levobupivacaine + 2 mg/kg ketamine; and group M: levobupivacaine + 2 mg/kg magnesium sulfate. The block was administered preoperatively before anesthesia induction. Postoperatively, hemodynamics, visual analog scale scores, the first request for analgesia, total analgesic consumption, and side effects were observed for 48 hours. Results: The total amount of Morphine rescue analgesia was significantly lower in groups M (7.00 ± 0.61 mg) and K (7.50 ± 0.58 mg) than in group C (14.40 ± 3.47 mg) during the first 48 h postoperatively. Nine (45%) patients in group M and 13 (65%) patients in K, compared with 20 (100%) patients in group C, requested analgesia. The time to first request of analgesia was significantly longer in groups M (30 h) and K (24 h) than in group C (7 h). No hemodynamic changes or serious side effects were observed. Conclusion: Magnesium sulphate and ketamine seem to be both effective adjuvants to levobupivacaine in ESP blocks for postoperative analgesia in patients undergoing MRM, with slightly better analgesia provided by magnesium sulphate.
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CD45 is a transmembrane glycoprotein and protein tyrosine phosphatase expressed on the surface of all nucleated hematopoietic cells. While there is increasing evidence demonstrating the involvement of CD45 in immune system regulation, no information on CD45 expression in inflammation and sepsis is currently available. Therefore, we determined the CD45 surface expression on granulocytes, lymphocytes, and monocytes in patients with COVID-19 and healthy volunteers in both absence and presence of lipopolysaccharide (LPS). Following approval by the local ethics committee, whole blood samples were obtained from patients with COVID-19 infection on day 1 of hospital admission and healthy volunteers. Samples were incubated in absence and presence of LPS and CD45 was measured in granulocytes, lymphocytes, and monocytes using flow cytometry. In comparison with healthy individuals, COVID-19 patients showed an increased CD45 expression on the surface of granulocytes (+35%, p < 0.02) and lymphocytes (+39%, p < 0.0001), but a reduced CD45 expression on monocytes (−35%, p < 0.0001). LPS incubation of whole blood from healthy individuals increased the CD45 expression on granulocytes (+430%, p < 0.0001), lymphocytes (+32%, p = 0.0012), and monocytes (+36%, p = 0.0005), respectively. LPS incubation of whole blood samples from COVID-19 patients increased the CD45 expression on granulocytes and monocytes, and decreased the CD45 expression on lymphocytes. In conclusion, CD45 expression on leucocytes is altered: (1) in COVID-19 patients, and (2) in in vitro endotoxemia in a complex cell-specific way, thus representing a new immunoregulatory mechanism.
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BACKGROUND: Buccal dexmedetomidine (DEX) produces adequate preoperative sedation and anxiolysis when used as a premedication. Formulating the drug as a gel decreases oral losses and improves the absorption of buccal DEX. We compared pharmacokinetic and pharmacodynamic properties of 3 doses of buccal DEX gel formulated in our pharmaceutical laboratory for sedative premedication in women undergoing modified radical mastectomy for breast cancer. METHODS: Thirty-six patients enrolled in 3 groups (n = 12) to receive buccal DEX gel 30 minutes before surgery at 0.5 µg/kg (DEX 0.5 group), 0.75 µg/kg (DEX 0.75 group), or 1 µg/kg (DEX 1 group). Assessments included plasma concentrations of DEX, and pharmacokinetic variables calculated with noncompartmental methods, sedative, hemodynamic and analgesic effects, and adverse effects. RESULTS: The median time to reach peak serum concentration of DEX (Tmax) was significantly shorter in patients who received 1 µg/kg (60 minutes) compared with those who received 0.5 µg/kg (120 minutes; P = .003) and 0.75 µg/kg (120 minutes; P = .004). The median (first quartile-third quartile) peak concentration of DEX (maximum plasma concentration [Cmax]) in plasma was 0.35 ng/mL (0.31-0.49), 0.37 ng/mL (0.34-0.40), and 0.54 ng/mL (0.45-0.61) in DEX 0.5, DEX 0.75, and DEX 1 groups (P = .082). The 3 doses did not produce preoperative sedation. The 1 µg/kg buccal DEX gel produced early postoperative sedation and lower intraoperative and postoperative heart rate values. Postoperative analgesia was evident in the 3 doses in a dose-dependent manner with no adverse effects. CONCLUSIONS: Provided that it is administered 60-120 minutes before surgery, sublingual administration of DEX formulated as an oral-mucosal gel may provide a safe and practical means of sedative premedication in adults.
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Neoplasias de la Mama/cirugía , Dexmedetomidina/administración & dosificación , Dexmedetomidina/farmacocinética , Hipnóticos y Sedantes/administración & dosificación , Hipnóticos y Sedantes/farmacocinética , Mastectomía Radical Modificada , Premedicación , Administración Bucal , Adulto , Dexmedetomidina/sangre , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Composición de Medicamentos , Egipto , Femenino , Geles , Hemodinámica/efectos de los fármacos , Humanos , Hipnóticos y Sedantes/sangre , Persona de Mediana Edad , Absorción por la Mucosa Oral , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Intrathecal fentanyl in spinal anesthesia improves intra- and postoperative analgesia. Dexmedetomidine is a fascinating adjuvant with regards to neuraxial anesthesia in children experiencing surgery for abdominal malignancy. PATIENTS AND METHODS: After endorsement by the institutional reviewing board (IRB) and guardians' written informed consent, this research was carried out on 60 pediatric malignancy patients scheduled for major abdominal surgery. Children were randomly distributed into three groups (20 patients each): Group C: given 2 mL of bupivacaine 0.5% (0.4 mg/kg) intrathecally, injected gradually over 20 seconds. Group F: the same as group C, plus fentanyl 0.2 µg/kg. Group D: the same as group C, plus dexmedetomidine 0.2 µg/kg. Pain at zero, two, four, six, 12, 18, and 24 hours postoperatively was evaluated by Face, Legs, Activity, Crying, and Consolability (FLACC) score. First analgesic request and postoperative unfavorable effects were recorded for 24 hours postoperatively. RESULTS: A significant decrease was recognized in the mean FLACC score in groups D and F at six, eight, and 12 hours postoperatively, in contrast to group C (P ≤ 0.05). First analgesic request was significantly prolonged in group D (7.67 ± 0.57 hours), in contrast to groups F and C (5.40 ± 1.09 hours and 4.23 ± 3.27 hours, respectively, P < 0.04). Paracetamol utilization was significantly decreased in group D (316.67 ± 28.86 mg), in contrast to group C (391.00 ± 52.00 mg, P < 0.03), without a significant difference between group F (354.44 ± 46.67 mg) and groups D and C (P > 0.05). CONCLUSIONS: Adding dexmedetomidine and fentanyl to intrathecal bupivacaine improved postoperative analgesia following abdominal surgery for cancer in children, with better overall analgesia of dexmedetomidine compared with fentanyl.
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Dexmedetomidina , Neoplasias , Analgésicos , Anestésicos Locales , Bupivacaína , Niño , Método Doble Ciego , Fentanilo , Humanos , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
BACKGROUND: Pharmacologic treatment is not successful in all cases of postmastectomy pain syndrome (PMPS). Some patients continue suffering pain while taking their medications, and others cannot tolerate the side effects of antineuropathic analgesics. Radiofrequency technology has provided promising results in the management of chronic neuropathic pain. OBJECTIVES: Considering that affection of intercostobrachial nerves are the main reason behind PMPS, we aimed to evaluate and compare the analgesic efficacy of pulsed radiofrequency (PRF) when delivered either on thoracic dorsal root ganglion (DRG) of intercostobrachial nerves (thoracic DRG 2, 3, and 4) or their corresponding thoracic paravertebral nerves (PVNs). STUDY DESIGN: Prospective randomized-controlled clinical trial. SETTINGS: Interventional pain unit, tertiary center, university hospital. METHODS: Sixty-four patients complaining of PMPS were randomized to either group DRG (n = 32) that received PRF on thoracic DRG, or group PVN (n = 32) that received PRF on thoracic PVN. The outcome variables were that the patients showed > 50% reduction in their visual analog scale (VAS) pain score; the VAS pain score and global perceived effect (GPE) was evaluated during a 6-month follow-up period. RESULTS: The percentage of patients who showed > 50% reduction of their VAS pain score was significantly higher in group DRG compared with group PVN, assessed at 4 and 6 months postprocedure (23/29:79.3% vs. 13/29:44.8%; P = 0.007) and (22/29:75.9% vs. 7/29:24.1%; P < 0.001), respectively, however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure (DRG vs. PVN), (21/29: 72.4% vs. 21/29: 72.4%; P = 0.542), (24/29: 82.8% vs. 23/29: 79.9%; P = 0.778), and (24/29: 82.8% vs. 19/29: 65.5%; P = 0.136), respectively. There was a statistically significant reduction of VAS pain score at 4 and 6 months (DRG vs. PVN, mean ± standard deviation, 2.9 ± 2 vs. 3.9 ± 1.5; mean difference (95% confidence interval), 1 (0.06:1.9); P = 0.038; 3 ± 1.94 vs. 5.1 ± 1.5; mean difference (95% confidence interval), 1.9 (1:2.9); P < 0.001, respectively), however, the 2 groups did not significantly differ at 1, 2, and 3 months postprocedure. With regard to the patient's satisfaction (i.e., GPE), assessed at 3 and 6 months postprocedure, there was a significantly higher satisfaction in group DRG compared with group PVN (median [interquartile range (IQR)], 6 (5:7) vs. 3 (2:4);P < 0.001), however, the patient's satisfaction was similar between groups at 3 months postprocedure: median (IQR), 6 (4:7) vs. 6 (5:6); P = 0.327. LIMITATIONS: The study follow-up period is limited to 6 months only. CONCLUSIONS: PRF of both the thoracic DRG and the thoracic PVN are effective treatments for PMPS; however, PRF of DRG provided a better long-term analgesic effect. Nevertheless, given the inherent risk of performing thoracic foraminal interventions and the technical difficulty of targeting thoracic DRG, we recommend that PRF of DRG should be reserved for cases that failed to gain adequate response to PRF of thoracic PVN in conjunction with medical treatment. KEY WORDS: Postmastectomy pain syndrome, radiofrequency, dorsal root ganglion, paravertebral nerve.
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Ganglios Espinales , Mastectomía/efectos adversos , Dolor Postoperatorio/terapia , Tratamiento de Radiofrecuencia Pulsada/métodos , Nervios Torácicos , Adulto , Neoplasias de la Mama/cirugía , Dolor Crónico/etiología , Dolor Crónico/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neuralgia/etiología , Neuralgia/terapia , Satisfacción del Paciente , Estudios Prospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Transversus abdominis plane (TAP) block used for management of surgical abdominal pain by injecting local anesthetics into the plane between the internal oblique and transversus abdominis muscles. We aimed to explore the effect of adding morphine to bupivacaine in ultrasound guided TAP-block in patients undergoing lower abdominal cancer surgery. STUDY DESIGN: Randomized, double-blind, prospective study. Clinical trial identifier: NCT02566096. SETTING: Academic medical center. PATIENTS: Sixty patients were enrolled in this study after ethical committee approval. INTERVENTIONS: Patients divided into 2 groups (30 each): Bupivacaine group (GB): given ultrasound guided TAP-block 20ml 0.5% bupivacaine diluted in 20ml saline; Morphine group (GM): given ultrasound guided TAP-block with 20ml 0.5% bupivacaine+10mg morphine sulphate diluted in 20ml saline. MEASUREMENTS: Patients were observed for total morphine consumption, time for first request of rescue analgesia, sedation scores, hemodynamics and side effects for 24h postoperatively. RESULTS: Morphine added to bupivacaine in TAP block compared to bupivacaine alone reduced total morphine consumption (5.33±1.28mg) (10.70±3.09mg) respectively (p<0.001), prolonged the time to first request of analgesia (10.40±4.96h) (6.97±3.26h) respectively (p<0.008), with a statistically significant decrease in (VAS-M) in GM compared with GB at 12h postoperatively (p<0.002). No significant differences in hemodynamics, respiratory rate, oxygen saturation, sedation score, and side effects except for nausea were observed (p>0.05). CONCLUSION: Addition of morphine to bupivacaine in TAP block is effective method for pain management in patients undergoing major abdominal cancer surgery without serious side effects.
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Bupivacaína/administración & dosificación , Morfina/administración & dosificación , Bloqueo Nervioso/métodos , Dolor Postoperatorio/tratamiento farmacológico , Músculos Abdominales/diagnóstico por imagen , Neoplasias Abdominales/cirugía , Centros Médicos Académicos , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Anestésicos Locales/administración & dosificación , Anestésicos Locales/efectos adversos , Bupivacaína/efectos adversos , Método Doble Ciego , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Morfina/efectos adversos , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
BACKGROUND AND OBJECTIVES: Poorly controlled postoperative pain is strongly associated with the development of chronic pain. We aimed to investigate the effect of topical morphine (in 1 of 3 doses: 5, 10, or 15 mg) on acute and chronic neuropathic pain after modified radical mastectomy for cancer breast. METHODS: In this registered clinical trial (ClinicalTrials.gov identifier: NCT02462577), 90 patients were allocated to receive 10 mL plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine (designated by the group names Morphine5, Morphine10, and Morphine15, respectively). The combination was diluted by saline 0.9% to 20 mL and irrigated in the wound before skin closure. Groups were compared for the following: time to first postoperative analgesia; intravenous patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs scores in first and third postoperative months. RESULTS: No patient in the Morphine15 group requested postoperative PCA morphine versus 19 and 8 in the Morphine5 and Morphine10 groups, respectively (P < 0.002). Time to first analgesic request and total consumption of PCA morphine analgesia were 7.31 ± 3.12 hours versus 14.00 ± 3.54 hours (P < 0.000) and 1.42 ± 0.50 mg versus 1.00 ± 0.00 mg (P = 0.371) in the Morphine5 and Morphine10 groups, respectively. Lowest scores on visual analog pain scale at rest (P < 0.001) and visual analog pain scale during movement (P < 0.01) were recorded in the Morphine15 group, followed by Morphine10 then Morphine5 group. Lowest Leeds Assessment of Neuropathic Symptoms and Signs scores were recorded in the Morphine15 group in the first month (1.10 ± 0.37 vs 5.76 ± 3.26 and 4.73 ± 2.87, P < 0.0001) and third postoperative month (4.40 ± 1.77 vs 6.33 ± 3.21 and 5.43 ± 2.67, P < 0.006) compared with Morphine5 and Morphine10 groups, respectively. No patient in the Morphine15 group developed chronic pain versus 4 and 2 in Morphine5 and Morphine10 groups, respectively. CONCLUSIONS: Topical morphine controlled acute postmastectomy pain in a dose-dependent manner and reduced the incidence and severity of chronic postmastectomy pain syndrome.
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Dolor Agudo/prevención & control , Analgésicos Opioides/administración & dosificación , Neoplasias de la Mama/cirugía , Dolor Crónico/prevención & control , Mastectomía Radical Modificada/efectos adversos , Morfina/administración & dosificación , Neuralgia/prevención & control , Dolor Postoperatorio/prevención & control , Dolor Agudo/diagnóstico , Dolor Agudo/etiología , Administración Tópica , Adulto , Analgesia Controlada por el Paciente , Analgésicos Opioides/efectos adversos , Dolor Crónico/diagnóstico , Dolor Crónico/etiología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Egipto , Femenino , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Morfina/efectos adversos , Neuralgia/diagnóstico , Neuralgia/etiología , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Estudios Prospectivos , Irrigación Terapéutica , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare the analgesic effect of combined intrathecal morphine and dexmedetomidine with either drug alone for postoperative analgesia in patients undergoing major abdominal cancer surgery. METHODS: Ninety patients were allocated to receive intrathecal 10 mg bupivacaine 0.5% (bupivacaine group, n = 30), 10 mg bupivacaine 0.5% and 0.5 mg morphine (Morphine Group, n = 30), or 10 mg bupivacaine 0.5%, 0.5 mg morphine and 5 µg dexmedetomidine (morphine-Dex group, n = 30). The groups were compared with time to first postoperative analgesia, iv patient-controlled analgesia (PCA) morphine consumption, pain scores, hemodynamics, sedation, and adverse events in the first 48h postoperative. RESULTS: The time to first use of morphine PCA was longer in morphine (22.13 ± 5.21h, P = 0.000) and morphine-Dex (23.46 ± 4.69h, P = 0.000) groups compared with bupivacaine group (0.50 ± 0.09h). Dexmedetomidine addition increased the duration of intrathecal morphine (ITM) analgesia by 1.33 h (P = 0.485). Morphine consumption was less in morphine (10.83 ± 2.96 mg, P = 0.000) and morphine-Dex (11.00 ± 3.32 mg, P = 0.000) groups than in bupivacaine group (27.5 ± 4.30 mg), with a nonsignificant difference between morphine and morphine-Dex groups (P = 0.375). Morphine and morphine-Dex groups showed lower pain scores (P < 0.001). Intraoperative blood pressure and heart rate were lower in morphine and morphine-Dex groups (P < 0.05) with no significant difference between groups in postoperative hemodynamics. Patients in bupivacaine group showed a higher incidence of postoperative nausea (P < 0.03) and vomiting (P < 0.01), while patients in morphine and morphine-Dex groups had a higher incidence of pruritus (P < 0.02). CONCLUSIONS: Our results do not support improved analgesia with the combination of intrathecal morphine and dexmedetomidine, despite the absence of significant adverse effects.
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Analgésicos Opioides/administración & dosificación , Dexmedetomidina/administración & dosificación , Morfina/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Neoplasias Gástricas/cirugía , Adulto , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Bupivacaína/administración & dosificación , Quimioterapia Combinada , Femenino , Frecuencia Cardíaca/efectos de los fármacos , Frecuencia Cardíaca/fisiología , Humanos , Inyecciones Espinales , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/fisiopatología , Neoplasias Gástricas/fisiopatologíaRESUMEN
BACKGROUND: Despite 30 years of clinical research, we still do not know the optimal dose of intrathecal morphine (ITM) when used alone. OBJECTIVES: A safety investigation and comparison of the analgesic efficacy of ITM 0.2 mg, 0.5 mg, and 1 mg in patients undergoing major abdominal cancer surgery. STUDY DESIGN: A randomized, double-blind trial. SETTING: Academic medical center. METHODS: Ninety patients were randomly assigned to receive morphine intrathecally either 0.2 mg (Group I, ITM 0.2 mg, n = 30), 0.5 mg (Group II, ITM 0.5 mg, n = 30), or 1 mg (Group III, ITM 1 mg, n = 30) dissolved in 5 mL physiological saline before general anesthesia. Assessment parameters included hemodynamics, respiratory rate, peripheral arterial oxygenation, sedation score, pain severity, time of first analgesic request, total analgesic consumption, and side effects in the first 72 hours. RESULTS: The mean time to first request for rescue analgesia was significantly prolonged in Group II (22.13 ± 5.21 hours, P < 0.001) and Group III (30.83 ± 4.89 h, P < 0.001), compared with Group I (0.50 ± 0.66 hours). The mean tramadol consumption dose was significantly reduced in Group II (383.33 ± 91.28 mg, P < 0.001) and Group III (300 ± 69.48 mg, P < 0.001) compared with Group I (770 ± 114.92 mg). Patients received 1 mg ITM showed lower VAS scores in the first 48 h postoperative (P < 0.04) compared with Group I and Group II. No significant differences were observed in the mean systolic and diastolic blood pressure values, respiratory rate, and peripheral arterial oxygen saturation between groups. Lower mean heart rate values were observed in Group III patients at 6 hours (P < 0.01) and 12 hours (P < 0.03) postoperative compared with Group I and Group II patients. Six patients (20%) in Group II and 8 (26.7%) in Group III exhibited pruritus compared with 2 patients (6.66%) in Group I (P < 0.01). No intergroup statistical differences were observed for other studied side effects. LIMITATIONS: This study is limited by its small sample size. CONCLUSION: One mg ITM provided superior analgesia for 48 hours postoperative compared with 0.2 mg and 0.5 mg ITM with a nonsignificant difference in the incidence of side effects. Further studies of larger sample size are recommended to confirm these findings.
Asunto(s)
Neoplasias Abdominales/cirugía , Dolor Abdominal/tratamiento farmacológico , Analgésicos Opioides/uso terapéutico , Morfina/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/efectos adversos , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Humanos , Inyecciones Espinales , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Morfina/efectos adversos , Dimensión del Dolor/efectos de los fármacos , Estudios Prospectivos , Resultado del TratamientoRESUMEN
STUDY OBJECTIVES: To investigate the analgesic effect of adding clonidine to topical bupivacaine for acute and chronic postmastectomy pain. DESIGN: Randomized, prospective, double-blinded study. SETTING: Cancer institute and university hospital. PATIENTS: 140 ASA physical status 1 and II women, aged 30 to 50 years, scheduled for modified radical mastectomy with axillary dissection for breast carcinoma. INTERVENTIONS: Patients were divided into 4 groups of 35 patients each, to receive either saline 0. 9% (control group), plain bupivacaine 0.5% (Bupivacaine group), plain bupivacaine 0.5% and 150 µg of clonidine (Clonidine150 group), or plain bupivacaine 0.5% and 250 µg of clonidine (Clonidine250 group). Study drugs were irrigated into the surgical field before skin closure. MEASUREMENTS AND MAIN RESULTS: Pain severity, time to first request of rescue analgesia, analgesic consumption, hemodynamics, and side effects were recorded in the first 48 hours postoperatively. The frequency of neuropathic pain was assessed using the Douleur Neuropathique 4-question survey (DN4) in the first and second postoperative months. Mean time to first postoperative analgesic request was significantly prolonged in the Bupivacaine (5.76 ± 0.85 hrs), Clonidine150 (11.6 ± 2.38 hrs), and Clonidine250 (17.4 ± 3.27 hrs) groups compared with the control group (1.86 ± 0.65 hrs). Postoperative tramadol consumption and visual analog scores (VAS) were significantly reduced in the Bupivacaine, Clonidine150, and Clonidine250 groups. Clonidine250 group patients had the lowest VAS scores from 2 to 48 hours postoperatively. Lower mean DN4 scores (P = 0.000) and a significantly reduced frequency of neuropathic pain (P < 0.04) were recorded in the Bupivacaine, Clonidine150, and Clonidine250 groups, with a nonsignificant difference noted among the treatment groups. CONCLUSIONS: The addition of clonidine to topical bupivacaine accentuated its early postoperative analgesic efficacy.