Caio Marcio Barros de Oliveira

Cytokines and Pain

BACKGROUND AND OBJECTIVES Cytokines are necessary for the inflammatory response, favoring proper wound healing. However, exaggerated proinflammatory cytokine production can manifest systemically as hemodynamic instability or metabolic derangements. The objective of this review was to describe the effects of cytokines in pain. CONTENTS This article reviews the effects of cytokines in pain. In diseases with acute or chronic inflammation, cytokines can be recognized by neurons and used to trigger several cell reactions that influence the activity, proliferation, and survival of immune cells, as well as the production and activity of other cytokines. Cytokines can be proinflammatory and anti-inflammatory. Proinflammatory cytokines are related with the pathophysiology of pain syndromes. Cells that secrete proinflammatory (IL-1, IL-2, IL-6, IL-7, and TNF) and anti-inflammatory (IL-4, IL-10, IL-13, and TGFβ) cytokines, the functions of each cytokine, and the action of those compounds on pain processing, have been described. CONCLUSIONS Cytokines have an important role in pain through different mechanisms in several sites of pain transmission pathways.

Lidocaína por via venosa intraoperatória

JUSTIFICATIVA E OBJETIVOS: Grande parte dos pacientes submetidos a operacao experimentam dor moderada a intensa, havendo necessidade de melhorar a tecnica analgesica. A lidocaina tem sido usada amplamente por via venosa para tratamento de dor cronica. O objetivo foi fazer uma revisao sobre o uso de lidocaina por via venosa para analgesia pos-operatoria. CONTEUDO: Foi realizada revisao dos aspectos farmacologicos da lidocaina, dos mecanismos de acao desse anestesico local e de estudos clinicos nos quais os autores empregaram lidocaina intraoperatoria. CONCLUSOES: A lidocaina venosa pode promover efeito analgesico para procedimentos cirurgicos, sendo mais uma alternativa para o tratamento da dor aguda. A realizacao de mais estudos controlados com diferentes intervencoes operatorias podera trazer mais informacoes sobre essa modalidade analgesica.

Citocinas e dor

JUSTIFICATIVA Y OBJETIVOS: Las citocinas son sustancias necesarias para la respuesta inflamatoria, favoreciendo la cicatrizacion apropiada de la herida. Sin embargo, la produccion exagerada de citocinas proinflamatorias a partir de la lesion puede manifestarse sistemicamente con la inestabilidad hemodinamica o disturbios metabolicos. El objetivo de esta revision fue describir los efectos de las citocinas en el dolor. CONTENIDO: Este articulo intenta hacer una revision de los efectos de las citocinas en el dolor. En enfermedades que se manifiestan con un proceso inflamatorio agudo o cronico, las citocinas pueden ser reconocidas por las neuronas y utilizadas para desencadenar diversas reacciones celulares que influyen en la actividad, proliferacion y sobrevida de la celula inmunologica, como tambien en la produccion y en la actividad de otras citocinas. Las citocinas pueden ser proinflamatorias y antiinflamatorias. Las proinflamatorias tienen una relacion con la fisiopatologia de los sindromes dolorosos. Ya se han descrito las celulas que segregan las citocinas, las citocinas proinflamatorias (IL-1, IL-2, IL-6, IL-7 y FNT) y antiinflamatorias (IL-4, IL-10, IL-13 y FTCβ), las funciones de cada citocina y tambien como ocurre la accion de esas sustancias en el proceso del dolor. CONCLUSIONES: Las citocinas desempenan un rol muy importante en el dolor, actuando por medio de diferentes mecanismos en varios locales de las vias de transmision del dolor.

Cetamina e analgesia preemptiva

JUSTIFICATIVA Y OBJETIVOS: Desde la descubierta de que la cetamina bloquea los receptores NMDA en los neuronios del cuerno dorsal de la medula, ella ha sido usada para inhibir o reducir la sensibilizacion central provocada por estimulos nociceptivos. Asi, este trabajo tiene por finalidad mostrar aspectos farmacologicos de la cetamina racemica y de su compuesto levogiro y su empleo en la analgesia preemptiva. CONTENIDO: Se presentan conceptos actuales sobre analgesia preemptiva, aspectos farmacologicos de la cetamina y su derivado levogiro, bien como estudios experimentales y clinicos sobre la cetamina y su uso en analgesia preemptiva. CONCLUSIONES: Aun no esta totalmente comprobada la eficacia de la cetamina en inhibir o reducir la sensibilizacion central provocada por estimulos nociceptivos. Probablemente eso se deba al uso de diferentes metodos de estudio y de analisis estadistica.

Intraoperative Intravenous Lidocaine

BACKGROUND AND OBJECTIVES Most patients undergoing surgery experience moderate to severe pain, indicating the need to improve the anesthetic technique. Intravenous lidocaine has been widely used in the treatment of chronic pain. The objective of this report was to review the use of intravenous lidocaine for postoperative analgesia. CONTENTS The pharmacologic aspects and mechanism of action of lidocaine as well as clinical studies in which the authors used intraoperative lidocaine were reviewed. CONCLUSIONS Intravenous lidocaine can promote analgesia in surgical procedures, representing another alternative for the treatment of acute pain. Controlled studies with different surgical interventions could bring more information on this modality of analgesia.

Neuralgia do trigêmeo bilateral: relato de caso

JUSTIFICATIVA Y OBJETIVOS: La neuralgia del nervio trigemino es una condicion intensamente dolorosa, caracterizada por brotes de dolor lancinantes y subitos, del tipo descarga electrica, con una duracion de pocos segundos a dos minutos y generalmente unilateral. Su incidencia anual es de cerca de 4,3 en 100.000 en la poblacion general, manifestandose bilateralmente en solo un 3% de esos casos. El objetivo de este articulo fue describir un caso raro de neuralgia del trigemino primario bilateral. RELATO DEL CASO: Paciente de 61 anos, del estado brasileno de Maranhao, casada, ama de casa, con antecedentes de hipertension arterial y hace seis anos quejandose de dolor intenso en V2-V3 a la izquierda, con una duracion de 5 a 10 segundos en la region lateral de la nariz y la mandibula, con empeoramiento al hablar, masticar y con una reduccion de la temperatura. Ya habia utilizado clorpromazina (3 mg a cada ocho horas), y carbamazepina (200 mg a cada ocho horas), durante seis meses sin que se le aliviase el dolor. Cuando se le examino fisicamente, presentaba alodinia termica y mecanica en regiones de V2-V3. Estaba usando gabapentina (1.200 mg al dia), con alivio parcial del dolor. Se le aumento entonces la gabapentina para 1.500 mg al dia y se le introdujo la amitriptilina 12,5 mg por la noche. La paciente desarrollo un ligero y esporadico dolor, con una reduccion de su intensidad a lo largo de 10 meses de tratamiento, siendo reducida progresivamente la gabapentina para 600 mg al dia y mantenida la amitriptilina 12,5 mg al dia. Despues de un ano, empezo a presentar dolor de caracteristicas similares en la region mandibular a la derecha, y mejoro con el aumento de la gabapentina para 900 mg al dia. No presentaba examenes de tomografia o resonancia magnetica de encefalo alterados. CONCLUSIONES: La carbamazepina es el farmaco de primera eleccion para el tratamiento de la neuralgia trigeminal, sin embargo la gabapentina ha sido cada vez mas utilizada como primera medida farmacologica o en casos refractarios a la terapia convencional.BACKGROUND AND OBJECTIVES Trigeminal neuralgia is an extremely painful condition characterized by recurrent episodes of sudden, lancinating, shock-like pain lasting from a few seconds to two minutes usually unilateral. It has an annual incidence of approximately 4.3 in 100,000 in the general population and only 3% of those cases present bilateral manifestation. The objective of this report was to describe a rare case of bilateral trigeminal neuralgia. CASE REPORT A 61 years old housewife from Maranhão, Brazil, married, with a history of hypertension, presented with a six-year history of severe pain in the left V2-V3 regions, lasting 5 to 10 seconds, in the lateral aspect of the nose and mandible, worsening by talking, chewing, and with a decrease in temperature. She had been treated with chlorpromazine (3 mg every eight hours) and carbamazepine (200 mg every eight hours) during six months without improvement. On physical exam, the patient presented thermal and mechanical allodynia in the V2-V3 regions. She was using gabapentin (1,200 mg/day) with partial relief of the pain. The dose of gabapentin was increased to 1,500 mg/day and amitriptyline 12.5 mg at night was added to the therapeutic regimen. The patient evolved with mild and sporadical pain and a reduction in pain severity during 10 months; the dose of gabapentin was progressively reduced to 600 mg/day, and amitriptyline was maintained at 12.5 mg/day. After one year, the patient developed similar pain in the region of the right mandible, which improved with an increase in the dose of gabapentin to 900 mg/day. Head CT and MRI did not show any abnormalities. CONCLUSIONS Carbamazepine is the first choice for the treatment of trigeminal neuralgia; however, the use of gabapentin as the first pharmacological choice or in cases refractory to conventional therapy has been increasing.

Bilateral trigeminal neuralgia: case report

JUSTIFICATIVA Y OBJETIVOS: La neuralgia del nervio trigemino es una condicion intensamente dolorosa, caracterizada por brotes de dolor lancinantes y subitos, del tipo descarga electrica, con una duracion de pocos segundos a dos minutos y generalmente unilateral. Su incidencia anual es de cerca de 4,3 en 100.000 en la poblacion general, manifestandose bilateralmente en solo un 3% de esos casos. El objetivo de este articulo fue describir un caso raro de neuralgia del trigemino primario bilateral. RELATO DEL CASO: Paciente de 61 anos, del estado brasileno de Maranhao, casada, ama de casa, con antecedentes de hipertension arterial y hace seis anos quejandose de dolor intenso en V2-V3 a la izquierda, con una duracion de 5 a 10 segundos en la region lateral de la nariz y la mandibula, con empeoramiento al hablar, masticar y con una reduccion de la temperatura. Ya habia utilizado clorpromazina (3 mg a cada ocho horas), y carbamazepina (200 mg a cada ocho horas), durante seis meses sin que se le aliviase el dolor. Cuando se le examino fisicamente, presentaba alodinia termica y mecanica en regiones de V2-V3. Estaba usando gabapentina (1.200 mg al dia), con alivio parcial del dolor. Se le aumento entonces la gabapentina para 1.500 mg al dia y se le introdujo la amitriptilina 12,5 mg por la noche. La paciente desarrollo un ligero y esporadico dolor, con una reduccion de su intensidad a lo largo de 10 meses de tratamiento, siendo reducida progresivamente la gabapentina para 600 mg al dia y mantenida la amitriptilina 12,5 mg al dia. Despues de un ano, empezo a presentar dolor de caracteristicas similares en la region mandibular a la derecha, y mejoro con el aumento de la gabapentina para 900 mg al dia. No presentaba examenes de tomografia o resonancia magnetica de encefalo alterados. CONCLUSIONES: La carbamazepina es el farmaco de primera eleccion para el tratamiento de la neuralgia trigeminal, sin embargo la gabapentina ha sido cada vez mas utilizada como primera medida farmacologica o en casos refractarios a la terapia convencional.BACKGROUND AND OBJECTIVES Trigeminal neuralgia is an extremely painful condition characterized by recurrent episodes of sudden, lancinating, shock-like pain lasting from a few seconds to two minutes usually unilateral. It has an annual incidence of approximately 4.3 in 100,000 in the general population and only 3% of those cases present bilateral manifestation. The objective of this report was to describe a rare case of bilateral trigeminal neuralgia. CASE REPORT A 61 years old housewife from Maranhão, Brazil, married, with a history of hypertension, presented with a six-year history of severe pain in the left V2-V3 regions, lasting 5 to 10 seconds, in the lateral aspect of the nose and mandible, worsening by talking, chewing, and with a decrease in temperature. She had been treated with chlorpromazine (3 mg every eight hours) and carbamazepine (200 mg every eight hours) during six months without improvement. On physical exam, the patient presented thermal and mechanical allodynia in the V2-V3 regions. She was using gabapentin (1,200 mg/day) with partial relief of the pain. The dose of gabapentin was increased to 1,500 mg/day and amitriptyline 12.5 mg at night was added to the therapeutic regimen. The patient evolved with mild and sporadical pain and a reduction in pain severity during 10 months; the dose of gabapentin was progressively reduced to 600 mg/day, and amitriptyline was maintained at 12.5 mg/day. After one year, the patient developed similar pain in the region of the right mandible, which improved with an increase in the dose of gabapentin to 900 mg/day. Head CT and MRI did not show any abnormalities. CONCLUSIONS Carbamazepine is the first choice for the treatment of trigeminal neuralgia; however, the use of gabapentin as the first pharmacological choice or in cases refractory to conventional therapy has been increasing.

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.

Anestesia tópica associada à sedação para facoemulsificação: experiência com 312 pacientes

BACKGROUND AND OBJECTIVES The use of topical anesthesia in cataract surgeries has been increasing, especially after the development of phacoemulsification. The objective of this study was to evaluate the efficacy of topical anesthesia associated with sedation for cataract extraction by phacoemulsification. METHODS A prospective study was conducted with 312 patients, ASA I and II, ages 41 to 89 years. Phacoemulsification was performed under topical anesthesia (5 minutes before surgery, by dripping 0.5% proximetacaine) associated with sedation (intravenous midazolam, 1 mg, administered 15 minutes before the surgery). Intravenous bolus of alfentanil, 125 microg, were administered under demand. Parameters, such as intraoperative pain, consumption of alfentanil, side effects, recovery time, and level of patient satisfaction were analyzed. RESULTS In the intraoperative period, 8 (2.6%) cases of bradycardia, 4 (1.3%) of epithelial edema, 2 (0.65%) of nausea, and 2 (0.65%) ruptures of the posterior capsule were observed. In the postoperative period, 15 (4.8%) cases of nausea, 6 (1.9%) cases of dizziness, 2 (0.65%) of vomiting, and 1 (0.32%) case of bradycardia were observed. The mean time of postoperative recovery was 21.77 minutes. Consumption of alfentanil varied from 125 microg to 1250 microg, with a mean consumption of 537 microg. Three hundred (96.2%) patients classified the technique as good and 12 (3.8%), as regular. Forty-two patients complained of pain sometime during surgery, and 4 (1.3%) patients said that if they needed another phacoemulsification, they would not like to undergo the same anesthetic technique. CONCLUSIONS In this study, topical anesthesia with sedation of patients undergoing cataract removal by phacoemulsification demonstrated to be effective, easy to apply, and had a very low incidence of complications.JUSTIFICATIVA E OBJETIVOS: A anestesia topica vem ganhando espaco nas operacoes de catarata, sobretudo apos os avancos advindos com a tecnica de facoemulsificacao. O objetivo desse estudo foi avaliar a eficacia da anestesia topica associada a sedacao para operacoes de catarata por facoemulsificacao. METODO: Estudo prospectivo de 312 pacientes, ASA I e II, com idades entre 41 e 89 anos. Foi realizada a facoemulsificacao sob anestesia topica (cinco minutos antes da operacao, por gotejamento com proximetacaina a 0,5%) associada a sedacao (midazolam, 1 mg, por via venosa, administrado 15 minutos antes da operacao). Alfentanil em bolus de 125 µg por via venosa foi administrado sob demanda. Variaveis como dor no intra-operatorio, consumo de alfentanil, efeitos colaterais, tempo de recupe\racao e nivel de satisfacao do paciente foram analisados. RESULTADOS: No periodo intra-operatorio foram observados oito (2,6%) casos de bradicardia, quatro (1,3%) de edema epitelial, dois (0,65%) de nauseas e duas (0,65%) rupturas de capsula posterior. No pos-operatorio foram observados 15 (4,8%) casos de nauseas, seis (1,9%) casos de tonturas, dois (0,65%) casos de vomitos e um (0,32%) caso de bradicardia. O tempo medio de recuperacao pos-operatoria foi de 21,77 minutos. O consumo de alfentanil variou entre 125 µg e 1.250 µg, com um consumo medio de 537 µg. Trezentos (96,2%) pacientes classificaram a tecnica anestesica como boa e 12 (3,8%) pacientes classificaram como regular. Quarenta e dois pacientes relataram dor em algum momento da operacao e quatro (1,3%) pacientes disseram que caso necessitassem realizar um novo procedimento de facoemulsificacao nao gostariam de ser submetidos a mesma tecnica anestesica. CONCLUSOES: A anestesia topica com sedacao em pacientes submetidos a operacoes de catarata por facoemulsificacao, neste estudo, demonstrou eficacia, facil aplicacao e complicacoes minimas.

Neuralgia del trigémino bilateral: relato de caso

JUSTIFICATIVA Y OBJETIVOS: La neuralgia del nervio trigemino es una condicion intensamente dolorosa, caracterizada por brotes de dolor lancinantes y subitos, del tipo descarga electrica, con una duracion de pocos segundos a dos minutos y generalmente unilateral. Su incidencia anual es de cerca de 4,3 en 100.000 en la poblacion general, manifestandose bilateralmente en solo un 3% de esos casos. El objetivo de este articulo fue describir un caso raro de neuralgia del trigemino primario bilateral. RELATO DEL CASO: Paciente de 61 anos, del estado brasileno de Maranhao, casada, ama de casa, con antecedentes de hipertension arterial y hace seis anos quejandose de dolor intenso en V2-V3 a la izquierda, con una duracion de 5 a 10 segundos en la region lateral de la nariz y la mandibula, con empeoramiento al hablar, masticar y con una reduccion de la temperatura. Ya habia utilizado clorpromazina (3 mg a cada ocho horas), y carbamazepina (200 mg a cada ocho horas), durante seis meses sin que se le aliviase el dolor. Cuando se le examino fisicamente, presentaba alodinia termica y mecanica en regiones de V2-V3. Estaba usando gabapentina (1.200 mg al dia), con alivio parcial del dolor. Se le aumento entonces la gabapentina para 1.500 mg al dia y se le introdujo la amitriptilina 12,5 mg por la noche. La paciente desarrollo un ligero y esporadico dolor, con una reduccion de su intensidad a lo largo de 10 meses de tratamiento, siendo reducida progresivamente la gabapentina para 600 mg al dia y mantenida la amitriptilina 12,5 mg al dia. Despues de un ano, empezo a presentar dolor de caracteristicas similares en la region mandibular a la derecha, y mejoro con el aumento de la gabapentina para 900 mg al dia. No presentaba examenes de tomografia o resonancia magnetica de encefalo alterados. CONCLUSIONES: La carbamazepina es el farmaco de primera eleccion para el tratamiento de la neuralgia trigeminal, sin embargo la gabapentina ha sido cada vez mas utilizada como primera medida farmacologica o en casos refractarios a la terapia convencional.BACKGROUND AND OBJECTIVES Trigeminal neuralgia is an extremely painful condition characterized by recurrent episodes of sudden, lancinating, shock-like pain lasting from a few seconds to two minutes usually unilateral. It has an annual incidence of approximately 4.3 in 100,000 in the general population and only 3% of those cases present bilateral manifestation. The objective of this report was to describe a rare case of bilateral trigeminal neuralgia. CASE REPORT A 61 years old housewife from Maranhão, Brazil, married, with a history of hypertension, presented with a six-year history of severe pain in the left V2-V3 regions, lasting 5 to 10 seconds, in the lateral aspect of the nose and mandible, worsening by talking, chewing, and with a decrease in temperature. She had been treated with chlorpromazine (3 mg every eight hours) and carbamazepine (200 mg every eight hours) during six months without improvement. On physical exam, the patient presented thermal and mechanical allodynia in the V2-V3 regions. She was using gabapentin (1,200 mg/day) with partial relief of the pain. The dose of gabapentin was increased to 1,500 mg/day and amitriptyline 12.5 mg at night was added to the therapeutic regimen. The patient evolved with mild and sporadical pain and a reduction in pain severity during 10 months; the dose of gabapentin was progressively reduced to 600 mg/day, and amitriptyline was maintained at 12.5 mg/day. After one year, the patient developed similar pain in the region of the right mandible, which improved with an increase in the dose of gabapentin to 900 mg/day. Head CT and MRI did not show any abnormalities. CONCLUSIONS Carbamazepine is the first choice for the treatment of trigeminal neuralgia; however, the use of gabapentin as the first pharmacological choice or in cases refractory to conventional therapy has been increasing.