RESUMO
BACKGROUND: Sterilization clinics often occur in remote places where anesthesia machines and compressed oxygen are unavailable. This study describes the use of total injectable anesthesia in dogs and cats presented for sterilization in a remote location. RESULTS: A total of 100 animals were sterilized; 26 female cats (CF), 22 male cats (CM), 28 female dogs (DF), and 24 male dogs (DM). CF were anesthetized with dexmedetomidine (20 mcg/kg), ketamine (8 mg/kg) and hydromorphone (0.1 mg/kg) IM. CM were anesthetized with dexmedetomidine (15 mcg/kg), ketamine (5 mg/kg) and hydromorphone (0.1 mg/kg) IM. Insufficient anesthesia in cats was treated with alfaxalone (1 mg/kg) IM. All cats were administered meloxicam at 0.3 mg/kg SQ. DF were anesthetized with dexmedetomidine (15 mcg/kg), ketamine (7-10 mg/kg) and hydromorphone (0.1 mg/kg) IM. DM were anesthetized with dexmedetomidine (15 mcg/kg), ketamine (5 mg/kg) and hydromorphone (0.1 mg/kg) IM. All dogs had IV catheter and endotracheal tube placed. If SpO2 < 91%, ventilation was assisted with an Ambu bag. Insufficient anesthesia in dogs was treated with alfaxalone (1 mg/kg) IV. All dogs were administered meloxicam at 0.2 mg/kg SQ. Following surgery, atipamezole (0.05-0.1 mg/kg) IM was administered to any patient that did not have voluntary movement. All patients survived and were discharged. Less than 25% of cats and male dogs required supplemental anesthesia. Fifty seven percent of female dogs required supplemental anesthesia. More than 89% of patients (in any group) required atipamezole administration. One cat recovered with agitation and hyperthermia (41.1C/ 106F). Some dogs required ventilatory assistance to remain normoxemic while anesthetized. CONCLUSION: Total injectable anesthesia can be accomplished for remote location sterilization clinics with minimal morbidity.
Assuntos
Anestesia Intravenosa/veterinária , Gatos/cirurgia , Cães/cirurgia , Orquiectomia/veterinária , Ovariectomia/veterinária , Antagonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Anestésicos Combinados/administração & dosagem , Animais , Dexmedetomidina/administração & dosagem , Equador , Feminino , Hidromorfona/administração & dosagem , Imidazóis/administração & dosagem , Ketamina/administração & dosagem , Masculino , Meloxicam/administração & dosagem , PregnanodionasRESUMO
PURPOSE: This study aimed to determine the current attitudes, perceptions, and practices of emergency medicine providers and nurses (RNs) regarding the discharge of adult patients from the emergency department (ED) after administration of opioid analgesics. METHODS: A cross-sectional survey was administered at 3 hospital sites with a combined annual ED census of >180,000 visits per year. All 59 attending emergency physicians (EPs), 233 RNs, and 23 advanced practice clinicians (APCs) who worked at these sites were eligible to participate. FINDINGS: Thirty-five EPs (59.3%), 88 RNs (37.8%), and 14 APCs (60.9%) completed the survey for an overall response rate of 51.75%. Most respondents were female (95 [69.9%]). The factor ranked most important to consider when discharging a patient from the ED after administration of opioids was the patient's functional status and vital signs (median, 2.00; interquartile range, 2.00-3.50). More RNs (84 [96.6%]) than EPs (29 [82.9%]) reported that developing an ED policy or guideline for safe discharge after administration of opioids is important to clinical practice (P = 0.02). Only 8 physicians (23.5%) reported that they did not prescribe intramuscular morphine, and 15 (42.9%) reported that they did not prescribe intramuscular hydromorphone. EPs (7 [20.0%]) and RNs (3 [3.4%]) differed in regard to whether they were aware if any patients to whom they administered an opioid had experienced an adverse drug-related event (P = 0.01). Most EPs (24 [68.6%]) and RNs (54 [61.4%]) believed that the decision for patient discharge should be left to both the emergency medicine provider and the RN. IMPLICATIONS: Most study participants believed that developing a policy or guideline for safe discharge after administration opioids in the ED is important to clinical practice. Only a few physicians reported that they did not prescribe intramuscular hydromorphone or morphine. Most participants believed the discharge decision after administration of opioids in the ED should be primarily determined by both the emergency medicine provider and the RN.
Assuntos
Analgésicos Opioides/administração & dosagem , Serviço Hospitalar de Emergência/estatística & dados numéricos , Alta do Paciente , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Medicina de Emergência , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Hidromorfona/administração & dosagem , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Percepção , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND AND OBJECTIVES: Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection. METHODS: This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0-10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function. RESULTS: Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (-12.6 [15.8] vs -3.8 [16.2]; P = 0.016). CONCLUSIONS: This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.
Assuntos
Analgesia Epidural/métodos , Anestésicos Locais/administração & dosagem , Hepatectomia/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Adulto , Idoso , Analgesia Epidural/efeitos adversos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/efeitos adversos , Pressão Arterial/efeitos dos fármacos , Coagulação Sanguínea/efeitos dos fármacos , Procedimentos Cirúrgicos Eletivos , Feminino , Hepatectomia/efeitos adversos , Humanos , Hidromorfona/administração & dosagem , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Pennsylvania , Estudos Prospectivos , Recuperação de Função Fisiológica , Respiração/efeitos dos fármacos , Espirometria , Fatores de Tempo , Resultado do TratamentoRESUMO
JUSTIFICATIVA E OBJETIVOS: A dor crônica é uma condição frequente na população mundial, sendo causa de perdas emocionais e econômicas importantes. A busca por fármacos analgésicos potentes, de longa duração de ação, que possam proporcionar estabilidade no controle em longo prazo, melhora da adesão ao tratamento com o mínimo de eventos adversos, tem crescido na última década. O mais novo membro desta classe de analgésicos é a hidromorfona OROS®, opioide forte agonista µ, que incorpora a tecnologia OROS® push-pullTM (ALZA Corporation, Mountain View, CA, USA), liberado hidromorfona, administrada por via oral, de forma constante, por 24h. O objetivo deste estudo foi descrever os aspectos farmacocinéticos e farmacodinâmicos, indicações e contra-indicações, bem como sumarizar os resultados dos principais artigos publicados, de relevância clínica, sobre a hidromorfona OROS®.CONTEÚDO: O cloridrato de hidromorfona é um analgésico opioide forte para a administração em dose única diária. A liberação controlada promove uma analgesia dose-dependente contínua, durante 24h de intervalo entre duas doses. Está indicada no tratamento da dor de moderada à intensa, crônica, maligna ou benigna. A dose inicial deve ser de 8 mg a cada 24h para pacientes que não estejam recebendo nenhum outro analgésico opioide. Para pacientes que estejam recebendo opioidespor via oral, a razão sugerida de conversão é de 5:1 de equivalentes de morfina por hidromorfona. Os estudos clínicos demonstraram um efeito analgésico contínuo ao longo de 24h em pacientes com dor moderada à intensa, maligna e não maligna. A formulação de liberação lenta proporciona analgesia estável, segura, sem a condição que comumente chamamos de "picos e vales", que favorece o aparecimento de efeitos adversos e um controle analgésico não ideal. A adesão ao tratamento e a comodidade posológica são inquestionáveis, com apenas uma administração diária. CONCLUSÃO: A hidromorfona OROS® parece ser uma opção analgésica segura e eficaz para o controle da dor crônica, de intensidade moderada à forte, não incidentais, malignas ou benignas, ajustando-se às exigências da Escada Analgésica da Organização Mundial da Saúde (3º degrau) e da analgesia multimodal.
BACKGROUND AND OJBECTIVES: Chronic pain is a common condition worldwide, being responsible for major emotional and economic losses. The search for potent long lasting analgesic drugs to provide stability for long term pain control and to improve adherence to treatment with minimum adverse events has grown during the last decade. The latest member of this class of analgesics is hydromorphone OROS®, strong µ agonist opioid, which incorporates the OROS® push-pullTM (ALZA Corporation, Mountain View, CA, USA) technology, which releases oral hydromorphone in a constant way during 24 hours. This review aimed at describing pharmacokinetic and pharmacodynamic aspects, indications and counterindications, as well as at summarizing results of major published articles of clinical relevance on hydromorphone OROS®.CONTENTS: Hydromorphone hydrochloride is a strong opioid analgesic for single daily dose administration. Controlled release promotes a continuousdose-dependent analgesia during the 24-hour interval between two doses. It is indicated to treat moderate to severe, chronic, malignant or benign pain. Initial dose should be 8 mg every 24 hours for patients not receiving any other opioid analgesic. For patients receiving oral opioids, suggested conversion ratio is 5:1 of morphine equivalents by hydromorphone. Clinical studies have shown a continuous analgesic effect for 24 hours in patients with moderate to severe, malignant or not malignant pain. The slow release formulation provides stable and safe analgesia without the condition we commonly call "peaks and valleys", which favors the onset of adverse effects and a less than ideal analgesic control. Adherence to treatment and dose convenience are unquestionable, with just one daily administration.CONCLUSION: Hydromorphone OROS® seems to be a safe and effective analgesic option to control chronic moderate to severe, non incidental, malignant or benign pain, in compliance with the requirements of World Health Organization?s Analgesic Stair (3rd step) and of multimodal analgesia.
Assuntos
Humanos , Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Hidromorfona/administração & dosagem , Preparações de Ação Retardada , Esquema de Medicação , Hidromorfona/efeitos adversos , Hidromorfona/farmacocinéticaRESUMO
OBJECTIVE: To compare induction with hydromorphone and diazepam (HydroD) or oxymorphone and diazepam (OxyD) followed by maintenance with isoflurane in dogs with induced hypovolemia. ANIMALS: 6 healthy mixed-breed dogs. PROCEDURE: The study used a crossover design. Measurements were obtained in normovolemic dogs during isoflurane. Hypovolemia was induced (blood loss of 30 mL/kg) and measurements repeated following recovery from anesthesia, after HydroD (hydromorphone, 0.1 mg/kg; diazepam, 0.2 mg/kg; i.v.) or OxyD (oxymorphone, 0.05 mg/kg; diazepam, 0.2 mg/kg; i.v.), after another dose of the same opioid, during administration of isoflurane (end-tidal concentration, 0.9%), and after glycopyrrolate (0.01 mg/kg, i.v.). Significant changes were identified. RESULTS: Induction effect was evident within 1 minute. All dogs were intubated after the second dose of opioid. No significant differences were found between inductions. The HydroD decreased heart rate (mean +/- SEM, -41 +/- 9.8 beats/min), whereas both inductions increased stroke index (0.4 +/- 0.09 mL/kg/beat) and caused moderate respiratory depression. Cardiac index was decreased (-30.2 +/- 6.04 mL/kg/min) and there was minor metabolic acidosis during isoflurane following HydroD, compared with values for anesthetized normovolemic dogs. Glycopyrrolate increased heart rate (50 +/- 8.6 beats/min) and decreased systolic blood pressure (-23.2 +/- 4.87 mm Hg) in dogs induced with HydroD and decreased stroke index (-0.3 +/- 0.08 mL/kg/beat) for both inductions. CONCLUSIONS AND CLINICAL RELEVANCE: Similar effects were detected after administration of HydroD or OxyD in hypovolemic dogs. Either combination should be safe for use in hypovolemic dogs. Administration of glycopyrrolate was not beneficial.