José Osvaldo Barbosa Neto

Analgesic efficacy of the intra-articular administration of high doses of morphine in patients undergoing total knee arthroplasty.

BACKGROUND AND OBJECTIVES Although the efficacy of intraarticular (IA) morphine is still controversial, it has been shown that higher doses promote better results and consequently decrease postoperative analgesic consumption, characterizing a dose-dependent peripheral action. A controlled, randomized, double-blind study was undertaken to evaluate the efficacy of the intra-articular administration of 10 mg of morphine in patients undergoing total knee arthroplasty. METHODS Fifty patients undergoing total knee arthroplasty were randomly divided into two groups: the treatment group received 10 mg (1 mL) of intra-articular morphine diluted in 19 mL of NS, while the control group received the intra-articular administration of 20 mL of NS, both after closure of the capsule at the end of the surgery. On demand subcutaneous morphine was available for residual pain. The following parameters were evaluated: pain severity according to the numeric scale (NS), 2 h (M1), 6 h (M2), 12 h (M3), and 24 h (M4) after the IA injection; time until the first request of analgesic; analgesic consumption, and side effects. CONCLUSIONS The treatment group had lower NS than the control group in M1 and M2, while significant differences were not observed in the other moments. The time until the first request of analgesics was significantly higher in the treatment group, and analgesic consumption in the first 24 hours was also lower in this group. The incidence of side effects did not differ between both groups. We concluded that the postoperative IA administration of 10 mg of morphine promoted a longer period without rescue analgesics and reduced their consumption in the first 24 hours.

Eficácia analgésica do uso de dose alta de morfina intra-articular em pacientes submetidos à artroplastia total de joelho

1. Professor Adjunto da Disciplina de Anestesiologia da UFMA; Responsavel pelo Servico de Dor do HU/UFMA e do Instituto Maranhense de Oncologia 2. Pos-graduando; Medico-residente de Anestesiologia no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo 3. Professor-adjunto da Disciplina de Ortopedia e Traumatologia da UFMA 4. Graduando em Medicina; Membro da Liga Academica de Dor, UFMA

Ressuscitação hemostática no choque hemorrágico traumático: relato de caso

JUSTIFICATIVA E OBJETIVOS: O objetivo deste artigo e relatar um caso em que a estrategia damage control (RDC) com ressuscitacao hemostatica foi usada com sucesso em paciente politraumatizada com choque hemorragico grave. RELATO DE CASO: Paciente de 32 anos com choque hemorragico grave por politraumatismo com fratura de bacia, que evoluiu com acidose, coagulopatia e hipotermia. Durante a ressuscitacao volemica, a paciente recebeu transfusao de hemocomponentes - plasma fresco congelado/concentrado de plaquetas/concentrado de hemacias, na razao de 1:1:1. Evoluiu no periodo intraoperatorio, com melhora dos parâmetros perfusionais, e prescindiu de drogas vasoativas. No fim da operacao a paciente foi levada para unidade de terapia intensiva e teve alta no setimo dia de pos-operatorio. CONCLUSAO: A terapeutica ideal do choque hemorragico traumatico ainda nao esta estabelecida, porem a rapidez no controle da hemorragia e do resgate perfusional e protocolos terapeuticos bem definidos sao as bases para se evitar a progressao da coagulopatia e a refratariedade do choque.

Central neuropathic pain

BACKGROUND AND OBJECTIVES: Central pain, classified as neuropathic, is defined as a painful syndrome caused by injury to central nervous system structures. This is one of the most complexes, intriguing and difficult to treat syndromes. This study aimed at promoting a narrative review including the concept of central pain, its intercurrent symptoms which are important for the diagnosis, and different available treatments, indications, results and complications. CONTENTS: Relevant articles available in Medline, Scielo, Cochrane Library and Pubmed databases in the last 10 years were selected by means of keywords: chronic neuropathic pain, central neuropathic pain, central pain. CONCLUSION: Central painful syndrome is diagnosed by means of neurological clinical evaluation. It is often refractory to clinical and neuromodulatory treatment, its management should be multimodal and allow for rehabilitation.

Hemostatic resuscitation in traumatic hemorrhagic shock: case report

Abstract Background and objectives The aim of this paper is to report a case in which the damage control resuscitation (DCR) approach was successfully used to promote hemostatic resuscitation in a polytraumatized patient with severe hemorrhagic shock. Case report Female patient, 32 years of age, with severe hemorrhagic shock due to polytrauma with hip fracture, who developed acidosis, coagulopathy, and hypothermia. During fluid resuscitation, the patient received blood products transfusion of fresh frozen plasma/packed red blood cells/platelet concentrate at a ratio of 1:1:1 and evolved intraoperatively with improvement in perfusion parameters without requiring vasoactive drugs. At the end of the operation, the patient was taken to the intensive care unit and discharged on the seventh postoperative day. Conclusion The ideal management of traumatic hemorrhagic shock is not yet established, but the rapid control of bleeding and perfusion recovery and well-defined therapeutic protocols are fundamental to prevent progression of coagulopathy and refractory shock.

Bloqueio do sistema nervoso simpático para tratamento de dor do membro fantasma: relato de caso

JUSTIFICATIVA E OBJETIVOS: A sensacao do membro fantasma e um fenomeno que acomete pacientes submetidos a amputacao de qualquer um dos membros, e essa sensacao pode ser acompanhada ou nao de dor. Este relato teve por objetivo apresentar um caso no qual o bloqueio do sistema nervoso simpatico foi utilizado como adjuvante no tratamento da dor do membro fantasma. RELATO DO CASO: Paciente portador de carcinoma epidermoide de punho que evoluiu com dor do membro fantasma apos amputacao do antebraco esquerdo. Foi submetido a tratamento conservador e de reabilitacao fisica, porem a analgesia obtida com terapia farmacologica foi insuficiente e o paciente evoluiu com dor do coto de amputacao e dor mediada pelo sistema nervoso simpatico. Finalmente, o paciente foi submetido a bloqueio simpatico venoso seguido de bloqueio diagnostico da cadeia simpatica toracica com reducao significativa da dor. CONCLUSAO: Nesse caso foi utilizado o bloqueio do sistema nervoso simpatico por meio de infusao venosa de lidocaina, seguido de bloqueio da cadeia simpatica toracica como opcao terapeutica para dor do membro fantasma. Nessa sequencia, foi obtido alivio da dor, sem surgimento de efeitos adversos.

Bloqueio neurolítico subaracnoideo em paciente com dor oncológica refratária: relato de caso

BACKGROUND AND OBJECTIVES: The use of subarachnoid neurolytic blockade to control pain has decreased in recent years due to the introduction of new techniques, but it is still important to control refractory cancer pain. This study aimed at presenting a case of cancer pain where this technique was used to control pain. CASE REPORT: Male patient, 45 years old, with locally advanced anal canal scamous cell carcinoma and ulcerated lesion in perineal region with enterovesical fistula and local infection. Patient had severe pain with numerical verbal scale (NVS) = 10 and was being pharmacologically treated with high opioid doses and adjuvants without good response. Subarachnoid neurolytic blockade was induced with 5% phenol with significant pain relief; 20 minutes after the procedure patient has referred 80% relief. Improvement has remained for 21 days when patient died due to infectious complications. CONCLUSION: This case has illustrated the use of subarachnoid blockade with 5% phenol to control cancer pain. The conclusion is that for selected cases, where life expectation is limited, this technique may be successfully used.

Dor retal persistente após retossigmoidectomia: relato de caso

JUSTIFICATIVA E OBJETIVOS: Dor abdominal cronica apos intervencao cirurgica possui fisiopatologia ainda pouco estudada, sendo descrita apos cesariana, hernia inguinal, videolaparoscopia e colecistectomia. No andar inferior do abdomen, a proctalgia cronica tem sido descrita apos hemorroidectomia sendo caracterizada por dor a evacuacao acompanhada de urgencia para defecar. A dor cronica pos-operatoria persistente apos retossigmoidectomia videolaparoscopica e pouco frequente. O objetivo deste estudo foi relatar um caso de dor pos-operatoria persistente apos retossigmoidectomia videolaparoscopica, controlada com bloqueio anestesico bilateral do plexo hipogastrico. RELATO DO CASO: Paciente do sexo feminino, 54 anos, submetida a retossigmoidectomia com anastomose em colon transverso-retal, por videolaparoscopia. No pos-operatorio imediato evoluiu com dor retal em tenesmo, continua, de forte intensidade, com queimacao ocasional. Analgesicos nao opioides nao aliviavam a dor. Investigacao do quadro nao evidenciou complicacoes cirurgicas, sendo encaminhada para a equipe de controle de dor. Foi realizado bloqueio diagnostico bilateral de plexo hipogastrico superior com 4 mL de lidocaina a 1%, (sem vasoconstritor) por via transdiscal em L5/S1 guiado por radioscopia, que produziu alivio importante da dor. Permaneceu sem dor durante dois meses, sendo realizado novo bloqueio bilateral hipogastrico superior com 5 mL de lidocaina a 2% (sem vasoconstritor) por via transdiscal em L5/S1 guiado por radioscopia, com remissao importante da dor, atualmente controlada com uso ocasional de gabapentina (300 mg). CONCLUSAO: A dor retal pos-operatoria persistente foi controlada com o bloqueio anestesico bilateral do plexo hipogastrico e a duracao do alivio da dor foi prolongada, muito alem da meia-vida do anestesico local.