Alexandre Slullitel

Randomized Evidence for Reduction of Perioperative Mortality

OBJECTIVE With more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence. DESIGN AND SETTING A web-based international consensus conference. PARTICIPANTS More than 1,000 physicians from 77 countries participated in this web-based consensus conference. INTERVENTIONS Systematic literature searches (MEDLINE/PubMed, June 8, 2011) were used to identify the papers with a statistically significant effect on mortality together with contacts with experts. Interventions were considered eligible for evaluation if they (1) were published in peer-reviewed journals, (2) dealt with a nonsurgical intervention (drug/technique/strategy) in adult patients undergoing surgery, and (3) provided a statistically significant mortality increase or reduction as suggested by a randomized trial or meta-analysis of randomized trials. MEASUREMENTS AND MAIN RESULTS Fourteen interventions that might change perioperative mortality in adult surgery were identified. Interventions that might reduce mortality include chlorhexidine oral rinse, clonidine, insulin, intra-aortic balloon pump, leukodepletion, levosimendan, neuraxial anesthesia, noninvasive respiratory support, hemodynamic optimization, oxygen, selective decontamination of the digestive tract, and volatile anesthetics. In contrast, aprotinin and extended-release metoprolol might increase mortality. CONCLUSIONS Future research and health care funding should be directed toward studying and evaluating these interventions.

Tramadol wound infiltration is not different from intravenous tramadol in children: a randomized controlled trial

STUDY OBJECTIVE The purpose of this trial was to assess if tramadol wound infiltration is superior to intravenous (IV) tramadol after minor surgical procedures in children because tramadol seems to have local anesthetic-like effect. DESIGN Randomized double-blind controlled trial. SETTING Postanesthesia care unit. PATIENTS Forty children, American Society of Anesthesiologists physical status I or II, scheduled to elective inguinal hernia repair. INTERVENTIONS Children were randomly distributed in 1 of 2 groups: IV tramadol (group 1) or subcutaneous infiltration with tramadol (group 2). At the end of the surgery, group 1 received 2 mg/kg tramadol (3 mL) by IV route and 3-mL saline into the surgical wound; group 2 received 2 mg/kg tramadol (3 mL) into the surgical wound and 3-mL saline by IV route. MEASUREMENTS In the postanesthesia care unit, patients were evaluated for pain intensity, nausea and vomiting, time to first rescue medication, and total rescue morphine and dipyrone consumption. MAIN RESULTS Pain scores measured during the postanesthesia recovery time were similar between groups. Time to first rescue medication was shorter, but not statistically significant in the IV group. The total dose of rescue morphine and dipyrone was also similar between groups. CONCLUSIONS We concluded that tramadol was effective in reducing postoperative pain in children, and there was no difference in pain intensity, nausea and vomiting, or somnolence regarding IV route or wound infiltration.

Efeito da lidocaína venosa intraoperatória sobre dor e interleucina‐6 plasmática em pacientes submetidas a histerectomia

BACKGROUND AND OBJECTIVES Interleukin-6 (IL-6) is a predictor of trauma severity. The purpose of this study was to evaluate the effect of intravenous lidocaine on pain severity and plasma IL-6 after hysterectomy. METHOD A prospective, randomized, comparative, double-blind study with 40 patients, aged 18-60 years. G1 received lidocaine (2mg.kg(-1).h(-1)) or G2 received 0.9% saline solution during the operation. Anesthesia was induced with O2/isoflurane. Pain severity (T0: awake and 6, 12, 18 and 24hours), first analgesic request, and dose of morphine in 24hours were evaluated. IL-6 was measured before starting surgery (T0), five hours after the start (T5), and 24hours after the end of surgery (T24). RESULTS There was no difference in pain severity between groups. There was a decrease in pain severity between T0 and other measurement times in G1. Time to first supplementation was greater in G2 (76.0±104.4min) than in G1 (26.7±23.3min). There was no difference in supplemental dose of morphine between G1 (23.5±12.6mg) and G2 (18.7±11.3mg). There were increased concentrations of IL-6 in both groups from T0 to T5 and T24. There was no difference in IL-6 dosage between groups. Lidocaine concentration was 856.5±364.1 ng.mL(-1) in T5 and 30.1±14.2 ng.mL(-1) in T24. CONCLUSION Intravenous lidocaine (2mg.kg(-1).h(-1)) did not reduce pain severity and plasma levels of IL-6 in patients undergoing abdominal hysterectomy.

Can Neuraxial Anesthesia Reduce Perioperative Mortality

Neuraxial anesthesia results from injection of local anesthetics into the subarachnoid space (spinal anesthesia) and/or into the epidural space (epidural anesthesia). According to two recent systematic reviews, neuraxial anesthesia compared with general anesthesia may reduce postoperative mortality in surgical procedures, especially in patients with intermediate-to-high cardiac risk [1, 2]. In the first analysis, Guay et al. summarized nine Cochrane systematic reviews in order to assess whether anesthetic technique influences mortality after surgery [1]. Compared with general anesthesia, neuraxial anesthesia alone reduced perioperative mortality up to 30 days after surgery (risk ratio 0.71; 95 % confidence interval 0.53–0.94: analysis of 20 studies with a cumulative N = 3006) [1]. Compared with general anesthesia alone, combined neuraxial and general anesthesia had no significant effect on perioperative mortality up to 30 days after surgery (relative risk 1.07; 95 % confidence interval 0.76–1.51: analysis of 18 studies with a cumulative N = 3228) [1]. In the second analysis, Popping et al. evaluated the impact on mortality of concomitant epidural analgesia, compared with systemic analgesia, in adults having surgery under general anesthesia (cumulative N = 2201: ten randomized controlled trials published up until July 2012) [2]. The results showed that there was a significant reduction in mortality risk associated with epidural analgesia (3.1 % vs 4.9 %; odds ratio 0.60; 95 % confidence interval 0.39–0.93) [2]. The results obtained in these two recent systematic reviews were in agreement with the findings from earlier analyses published in 2000 [3, 4]. Despite these recent publications, there is ongoing debate about whether neuraxial blockade can reduce perioperative mortality. Recent large high-quality trials have focused on this important question. This chapter will review the main recent trials in this area and develop an evidence-based answer to this debate.

Experimental models for the study of neuropathic pain

JUSTIFICATIVA E OBJETIVOS: Os modelos ideais deveriam reproduzir apenas deficits sensitivos, como alodinea, hiperalgesia e dor espontânea por curtos periodos de tempo. Existem diversos tipos de modelos animais, que avaliam as diversas etiologias e manifestacoes da dor neuropatica. Alguns modelos estudam os mecanismos perifericos e outros estudam mecanismos centrais da dor neuropatica. Esta revisao enfoca os modelos animais mais comumente utilizados para pesquisa em dor neuropatica. CONTEUDO: Sao descritos modelos animais baseados em ligadura de nervos perifericos que sao mais comumente empregados. De todos os modelos descritos nesta revisao, a lesao poupadora de nervo e aquela que produz anormalidades comportamentais mais reprodutiveis, por um periodo mais longo, ao passo que a constricao cronica do ciatico produz sinais comportamentais de neuropatia dolorosas menos previsiveis. Hemiseccao espinhal e lesao espinhal induzida por citocinas sao os modelos de escolha para estudar mecanismos de dor central. Outros modelos especificos sao utilizados para estudo da etiologia especifica da condicao dolorosa. CONCLUSAO: Como a dor neuropatica e multifatorial, diferentes modelos animais de dor neuropatica foram desenvolvidos ao longo dos anos que tem sido fundamentais para o estudo da dor neuropatica, uma vez que muito do conhecimento atual provem de estudos em ratos e camundongos. Sao necessarios maiores refinamentos nos modelos animais atualmente empregados e mais esforcos para determinar quais modelos animais podem ser mais preditivos, com menos vieses e com parâmetros de analises mais complexos e objetivos.