RESUMO
OBJECTIVE: Our goal was to evaluate acute postoperative pain in patients undergoing breast reconstructive surgery with Deep Inferior Epigastric Perforator Artery (DIEP) flap technique. MATERIAL AND METHODS: A retrospective study was carried out in patients undergoing DIEP-flap breast reconstruction between January 2014 and December 2019. The main goal was the evaluation of acute postoperative pain through visual analogic pain scale (VAS) at rest (VASr) and movement (VASm) in the immediate postoperative period in post-anesthesia care unit (0h), at 24 h and at 48 h post-intervention and intravenous (IV) morphine con- sumption, depending on whether General Anesthesia (GA group) or Combined Anesthesia (CA group) was performed. Secon- dary outcomes were chronic pain incidence, perioperative complications, postoperative nausea and vomiting (PONV), reinterven- tion and readmission rate and lenght of hospital saty. RESULTS: Sixty seven patients were included, 24 in GA group and 43 in CA group. CA group showed better VASm values at 24 h postintervention (p = 0.01). Postoperative IV morphine continuous infusion was required for acute pain management in 10.4% of patients (25% in GA vs 2.3% in the CA group; p = 0.004). Chronic pain rate was 13.4% (25% in GA vs 7% in the CA group; p = 0.038). Patients with worse initial pain control (VASr > 3 at 0 h) showed a higher incidence of chronic pain (66.6% vs 9.6%; p = 0.008). GA group presented higher rate of postoperative complications (66.6% vs 34.9%; p = 0,012), as well reintervention rate (58.3% vs 30.2%; p = 0.025). A sub-analysis showed that of the 10 patients (5 in the AC and 5 in the AG group) who reported poor initial pain control (VASr > 3 at 0 h), those belonging to the AC group, the IV morphine requirements were lower at post-anesthesia care unit (2 (0-5) mg vs 16 (9.5-23) mg; p = 0.016) and throughout the hospitalization period (4 (0-6) vs 24 (17.5-49, 2); p = 0.008). CONCLUSIONS: Locorregional techniques could offer a better control of postoperative acute pain and a lower incidence of chronic pain, without assuming implying a higher risk of complications related to them in patients undergoing breast reconstructive surgery by DIEP flap technique.
OBJETIVO: El objetivo del estudio fue evaluar el dolor agudo posoperatorio en las pacientes sometidas a cirugía de reconstrucción mamaria mediante colgajo de la arteria perforante epigástrica inferior profunda (colgajo DIEP). MATERIAL Y MÉTODOS: Se revisaron retrospectivamente las pacientes intervenidas de reconstrucción mamaria con colgajo DIEP entre enero de 2014 y diciembre de 2019. El objetivo principal fue la valoración del dolor agudo posoperatorio mediante la escala visual analógica (EVA) en reposo (EVAr) y movimiento (EVAm) en el posoperatorio inmediato en la unidad de Reanimación (0 h), a las 24 h y a las 48 h post-intervención y el consumo de morfina endovenosa (ev), según si se realizó una Anestesia General (AG) o una Anestesia Combinada (AC). Los objetivos secundarios fueron: incidencia de dolor crónico posoperatorio, complicaciones peroperatorias, náuseas y vómitos posoperatorios (NVPO), tasa de reintervención y reingreso y estancia hospitalaria. RESULTADOS: Se incluyeron 67 pacientes, 24 en el grupo AG y 43 en el grupo AC. El grupo AC mostró un mejor control del dolor en movimiento a las 24 h (p = 0,01). Un 10,4% de las pacientes precisaron infusión de morfina endovenosa (ev) para control del dolor agudo posoperatorio en reposo (25% en el grupo AG vs 2,3% en el grupo AC; p = 0,004). La incidencia de dolor crónico fue del 13,4% (25% en el grupo AG vs 7% en el grupo AC; p = 0,038). Las pacientes con mal control inicial del dolor (EVAr > 3 a las 0 h) presentaron mayor incidencia de dolor crónico (66,6% vs 9,6%; p = 0,008). El grupo AG presentó mayor tasa de complicaciones posoperatorias (66,6% vs 34,9%; p = 0,012), así como tasa de reintervención (58,3% vs 30,2%; p = 0,025). Un subanálisis mostró que de las 10 pacientes (5 en el grupo AC y 5 en el grupo AG) que refirieron un mal control inicial del dolor (EVAr > 3 a las 0 h), las pertenecientes al grupo AC requirieron menos morfina ev en unidad de reanimación postanestésica (2 (0-5) mg vs 16 (9,5-23) mg; p = 0,016) y durante toda su hospitalización (4 (0-6) vs 24 (17,5-49,2); p = 0,008). CONCLUSIONES: Las técnicas locorregionales podrían ofrecer un mejor control del manejo del dolor agudo y una menor incidencia de dolor crónico, sin suponer un mayor riesgo de complicaciones relacionadas con ellos en pacientes sometidas a cirugía reconstructiva mamaria mediante técnica de colgajo DIEP.
Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Dor Pós-Operatória/prevenção & controle , Mamoplastia/efeitos adversos , Retalho Perfurante/irrigação sanguínea , Anestesia por Condução/métodos , Anestesia Geral/métodos , Dor Pós-Operatória/epidemiologia , Reoperação , Medição da Dor , Estudos Retrospectivos , Terapia Combinada , Artérias Epigástricas/transplante , Náusea e Vômito Pós-Operatórios/epidemiologia , Morfina/administração & dosagemRESUMO
INTRODUCTION: Postoperative chronic pain (PCP) is defined as a discomfort that lasts more than expected or beyond 3 months after surgery. The recognition and study of this clinical entity has been gaining interest in the past few years. One of the main reasons is the great impact it can have on the quality of life of patients who suffer from it. OBJECTIVE: To describe the prevalence, risk factor and impact of PCP on patients subjected to different surgical procedures. MATERIALS AND METHODS: Search on MED- LINE/Pubmed, using the following terms: "chronic postsurgical pain", "chronic post operative pain", "chronic post operative pain", "chronic post surgical pain". Publications were then sieved using their title and abstract. RESULTS: Fifty-seven articles were analyzed. Ten to fifty percent of patients were reported as suffering PCP, with up to 10% incidence of severe pain. The main risk factors identified were the use of analgesics, pre-operative pain and type of surgery. Orthopedic surgery was highly associated with moderate to severe PCP within the first year. Twenty-one percent of patients referred PCP affected their quality of life and sleep; ability to carry out physical activity and return to work. CONCLUSION: The first approach to PCP is getting to know its impact and epidemiology. Surgical treatments can cause PCP, which will affect patient recovery and increase costs. Recognizing those patients at risk and establishing preventive management protocols could improve the quality of life of postsurgical patients.
INTRODUCCIÓN: El dolor crónico posoperatorio (DCPO) es aquel que aparece tras un procedimiento quirúrgico y se mantiene por más tiempo de lo esperado o más de tres meses luego de la cirugía. Es una entidad de reciente estudio y que tiene un gran impacto en la calidad de vida de los pacientes postoperados. OBJETIVO: Describir la prevalencia, factores de riesgo y el impacto del DCPO en pacientes sometidos a diferentes procedimientos quirúrgicos. MATERIAL Y MÉTODO: Se realizó una revisión de la literatura utilizando la base de datos MEDLINE/Pubmed. Los términos libres fueron "chronic postsurgical pain", "chronic postoperative pain", "chronic post operative pain", "chronic post surgical pain". Se realizó un cribado según título y resumen. RESULTADOS: Fueron analizados 57 artículos. De 10%-50% de los pacientes presentan DCPO y hasta 10% puede ser severo. El uso de analgésicos, presencia de dolor preoperatorio y especialidad quirúrgica han sido señalados como los principales factores de riesgo. La cirugía traumatológica aparece como la más asociada a DCPO moderado y severo a un año. Hasta 21% de los pacientes refieren que afecta su calidad de vida, el sueño, actividad física y reincorporación laboral. CONCLUSIÓN: El conocimiento de la epidemiología e impacto del DCPO es un primer acercamiento a este problema. Patologías de resolución quirúrgica pueden evolucionar con DCPO, afectando su recuperación y aumentando los costos que se desea contener. El reconocimiento de la población de riesgo y la instauración de protocolos preventivos pudiera mejorar la calidad de vida de los pacientes postoperados.
Assuntos
Humanos , Dor Pós-Operatória/epidemiologia , Doença Crônica , Fatores de RiscoRESUMO
The development of chronic pain after surgery or persistent postoperative pain is a significant public health problem that affects between 10%-56% of patients undergoing surgical intervention. It produces great restrictions of mobility, limitation of daily activities, dependence on opioids, anxiety, depression, a great alteration of the quality of life and important legal and medical-economic consequences. There is a very close correlation between acute postoperative pain, and persistent postoperative pain. For this reason, pain must be treated effectively in its acute phase to reduce the incidence of chronic pain after surgery. There are risk factors that predispose to its appearance and that must be known by the anesthesiologist. In an individualized and meticulous pre-anesthetic consultation, these risk factors can be detected, as well as the presence of surgical procedures related to chronic pain, with the purpose of the therapeutic approach of the first ones if necessary, and a good planning of the anesthetic and analgesic technique, which reduces the participation of the second, in the chronicity of acute pain. The role of the anesthesiologist in the pre-anesthetic consultation is essential for the planning of preventive and multimodal analgesia that, together with other resources, should reduce the incidence of persistent postoperative pain.
El desarrollo del dolor crónico después de la cirugía o dolor posoperatorio persistente, es un problema de salud pública significativo que afecta entre el 10%-56% de los pacientes sometidos a una intervención quirúrgica. Produce grandes restricciones de la movilidad, limitación de las actividades de vida diaria, dependencia a los opioides, ansiedad, depresión, una gran alteración de la calidad de vida e importantes consecuencias legales y médico-económicas. Hay una correlación muy estrecha entre el dolor agudo posoperatorio, y el dolor posoperatorio persistente. Por esa razón, el dolor debe ser tratado de manera eficaz en su fase aguda para disminuir la incidencia del dolor crónico posterior a la cirugía. Existen factores de riesgo que predisponen a su aparición y que deben ser conocidos por el anestesiólogo. En una consulta pre-anestésica individualizada y minuciosa, se podrán detectar estos factores de riesgo, como también la presencia de procedimientos quirúrgicos relacionados con el dolor crónico, con la finalidad del abordaje terapéutico de los primeros de ser necesario, y una buena planificación de la técnica anestésica y analgésica, que disminuya la participación de los segundos, en la cronicidad del dolor agudo. El rol del anestesiólogo en la consulta pre-anestésica, es fundamental para la planificación de la analgesia preventiva y multimodal que junto a otros recursos deberían disminuir la incidencia del dolor postoperatorio persistente.
Assuntos
Humanos , Dor Pós-Operatória/prevenção & controle , Dor Crônica/prevenção & controle , Analgésicos/administração & dosagem , Assistência PerioperatóriaRESUMO
OBJECTIVE: To evaluate the use of 5% lidocaine medicated plaster (LMP) for treating painful scars resulting from burns or skin degloving. PATIENTS AND METHODS: This was a prospective, observational case series study in individuals with painful scars <70 cm(2) in area, caused by burns or skin degloving. The study included a structured questionnaire incorporating demographic variables, pain evaluation using the numeric rating scale (NRS), the DN4 questionnaire, and measurement of the painful surface area. Patients with open wounds in the painful skin or with severe psychiatric disease were excluded. RESULTS: Twenty-one men and eight women were studied, aged (mean + standard deviation) 41.4 ± 11.0 years, with painful scars located in the upper extremity (n = 9), lower extremity (n = 19), or trunk (n = 1). Eleven patients (37.9%) had an associated peripheral nerve lesion. The scars were caused by burns (n = 13), degloving (n = 7), and/or orthopedic surgery (n = 9). The duration of pain before starting treatment with lidocaine plaster was 9.7 ± 10.0 (median 6) months. The initial NRS was 6.66 ± 1.84 points, average painful area 23.0 ± 18.6 (median 15) cm(2), and DN4 score 4.7 ± 2.3 points. The duration of treatment with LMP was 13.9 ± 10.2 (median 11) weeks. After treatment, the NRS was reduced by 58.2% ± 27.8% to 2.72 ± 1.65. The average painful area was reduced by 72.4% ± 24.7% to 6.5 ± 8.6 (median 5) cm(2). Nineteen patients (69%) showed functional improvement following treatment. CONCLUSION: LMP was useful for treating painful scars with a neuropathic component, producing meaningful reductions in the intensity of pain and painful surface area. This is the first time that a decrease in the painful area has been demonstrated in neuropathic pain using topical therapy, and may reflect the disease-modifying potential of LMP.