Josenília Maria Alves Gomes

Epidural nonsteroidal antiinflammatory drugs for cancer pain

A lthough pain relief with multimodal therapy is excellent in 45%-90% of cancer patients (l), dose escalation eventually occurs. The concurrent use of nonsteroidal antiinflammatory drugs (NSAIDS) to enhance opioid effects while decreasing the dose is recommended. Should NSAIDS and opioids fail, the spinal administration of opioids often results in improved analgesia with reduced opioid side effects w. Several reports have suggested a spinal site of action for NSAIDS (3-7) and synergy with spinal morphine (5). However, appropriate preclinical toxicity testing has not been performed for any commercially available NSAID, and intraspinal application is premature (8). We describe two cases in which epidural NSAIDS were administered by our ambulatory cancer patients without our initial knowledge or approval.

Currículo baseado em competências na residência médica

Competency was defined as a synthesis of knowledge, skills and attitudes that, when integrated, provide the individual with the integrated use of cognitive and technical resources to diagnose, treat and provide more benefits and less morbidity to the patient and reduce cost to the institutions. This definition was subsequently broadened, adding that it is context-dependent, demands experience and the capacity to reflect and continue learning. The aim of this study is to describe the curriculum implemented in the Anesthesiology Residency Program of the Walter Cantidio University Hospital (HUWC) at the Federal University of Ceara, which was based on six main competencies: communication, documentation, pre-operative care, intra-operative care, post-operative care, quality management and perioperative safety. The assessment tools used for the curriculum are also presented: cognitive testing, Direct Observation of Procedural Skills (DOPS), logbook, Multiple Source Feedback (MSF) and resident evaluation of the preceptors. The implementation of the curriculum andassessment processes aimed to broaden the qualification of both the anesthesiology resident sand the preceptors who train thes especialists.

Hemodynamic and metabolic evaluation of dexmedetomidine and remifentanil continuous infusion in videolaparoscopic cholecystectomy: comparative study

BACKGROUND AND OBJECTIVES Dexmedetomidine has been used for sedation and as coadjuvant drug in general anesthesia. This study aimed at evaluating cardiovascular and sympathetic-adrenal responses to tracheal intubation and pneumoperitoneum inflation with dexmedetomidine, as compared to remifentanil during anesthesia with sevoflurane for videolaparoscopic cholecystectomy. METHODS Forty two physical status ASA I or II patients, aged 25 to 55 years, were randomly distributed in two groups: GI and GII. Anesthesia was induced with 1 microg.kg-1 dexmedetomidine (GI) or remifentanil (GII) continuous infusion for 10 minutes, followed by propofol and cisatracurium. Anesthesia was maintained with 0.7 microg.kg-1.h-1 dexmedetomidine or 0.5 microg.kg-1.h-1 remifentanil continuous infusion and different sevoflurane concentrations. SBP, DBP and HR were recorded in the following moments: M1 - before initial drug infusion; M2 - after end of initial drug infusion; M3 - after tracheal intubation; M4 - before pneumoperitoneum; M5 - after pneumoperitoneum; M6 - five minutes after pneumoperitoneum deflation; M7 - after tracheal extubation. Epinephrine and norepinephrine were dosed in M4, M5 and M6. Sevoflurane expired concentration (EC), EC/MAC ratio and sevoflurane consumption were recorded in M4, M5 and M6. RESULTS SBP and DBP variations were higher in the dexmedetomidine group in M4 and M5. HR, epinephrine and norepinephrine levels were similar between groups. Sevoflurane EC was higher in M4 and M6 for GI, as well as EC/MAC ratio. There has been a higher sevoflurane consumption in GI, with a trend to less analgesics and anti-emetics consumption. CONCLUSIONS In the conditions of our study, dexmedetomidine has inhibited catecholamine release during tracheal intubation and pneumoperitoneum, however, has not prevented blood pressure increase in response to peritoneal inflation.JUSTIFICATIVA Y OBJETIVOS: La dexmedetomidina ha sido utilizada para sedacion y como coadjuvante en anestesia general. El objetivo de este estudio fue evaluar la respuesta cardiovascular y simpatico-adrenal a la intubacion traqueal y la insuflacion del pneumoperitoneo, comparandola al remifentanil durante anestesia con sevoflurano para colecistectomia videolaparoscopica. METODO: Fueron incluidos en el estudio 42 pacientes, estado fisico ASA I o II, con edades entre 25 y 55 anos, distribuidos aleatoriamente en dos grupos: GI y GII. La induccion de la anestesia fue realizada con infusion continua de 1 µg.kg-1 de dexmedetomidina (GI) o remifentanil (GII), durante 10 minutos, seguido de propofol y cisatracurio. La manutencion de la anestesia fue realizada con la infusion continua de 0,7 µg.kg-1.h-1 de dexmedetomidina o 0,5 µg.kg-1.h-1 de remifentanil y concentraciones variadas de sevoflurano. Fueron anotadas la PAS, PAD y FC en los momentos: M1 - antes del inicio de la infusion inicial de la droga; M2 - despues del termino de la infusion inicial de la droga; M3 - despues de la intubacion orotraqueal; M4 - antes del inicio del pneumoperitoneo; M5 - despues del pneumoperitoneo; M6 - cinco minutos despues desinsuflado el pneumoperitoneo, M7 - despues extubacion traqueal. En M4, M5 y M6 fueron dosadas adrenalina y noradrenalina. La concentracion expirada (CE) del sevoflurano, la relacion CE/CAM, consumen de sevoflurano fueron registrados en M4, M5 y M6. RESULTADOS: Variaciones en la PAS y PAD fueron mayores en el grupo de la dexmedetomidina en M4 y M5. A FC y los niveles de adrenalina y noradrenalina no presentaron diferencia entre los grupos. La CE del sevoflurano fue mayor en M4 y M6 en el GI, asi como la CE/CAM. En el GI, el consumen de sevoflurano fue mayor y se observo una tendencia para menor consumen de analgesicos y antiemeticos. CONCLUSIONES: En las condiciones de este estudio, la dexmedetomidina inhibio la liberacion de catecolaminas durante la intubacion orotraqueal y el pneumoperitoneo, sin embargo, no impidio el aumento de la presion arterial en respuesta a la insuflacion peritoneal.

Avaliação clínica comparativa entre a cetamina e a clonidina por via peridural no tratamento da dor crônica neuropática

BACKGROUND AND OBJECTIVES: Chronic pain results in an increased response of spinal cord dorsal horn neurons due to the action of several mediators released by neuronal terminals, including the agonists of N-methyl-D-aspartate receptors. In addition to sensory ascending pathways, inhibitory descending pathways modulate pain, including a2-adrenoceptors located on primary afferent terminals and on the spinal cord. This study was designed to investigate the anti-noxious effects of epidural ketamine (N-methyl-D-aspartate antagonist) or epidural clonidine (a2-adrenergic agonist) in the treatment of neuropathic chronic pain. METHODS: Twenty-six adult patients, with neuropathic chronic pain not responsive to conservative therapy, were randomly divided into two groups in this prospective double-blind study. All patients were regularly taking 50-75 mg oral amitriptyline at bedtime. Pain was evaluated through a 10 cm visual analog scale (VAS), with “zero” corresponding to “no pain” and 10 to “the worst possible pain”. A lumbar epidural catheter was inserted and test drugs were administered at 8 hour-intervals during 3 weeks. The ketamine group (KG) was given each time 1 mg.kg-1 preservative-free ketamine followed by 30 mg of 1% lidocaine. The clonidine group (Clo G) was given 30 µg preservative-free clonidine followed by 30 mg of 1% lidocaine (3 ml). RESULTS: Twenty-three patients were evaluated (KG-n=10; Clo G-n=13). Epidural administration of ketamine or clonidine in the proposed doses resulted in analgesia during epidural catheter maintenance (initial VAS 8-10 cm versus final VAS 0-3 cm) (p < 0.002). VAS scores remained maintained between 0 and 3 cm from 2 to 5 weeks following epidural catheter removal. CONCLUSIONS: Epidural ketamine or clonidine resulted in analgesia for neuropathic chronic pain refractory to conservative treatment and are effective alternatives when conventional treatment fails.JUSTIFICATIVA Y OBJETIVOS: El dolor cronico resulta en respuesta aumentada de los neuronios del cuerno dorsal de la medula espinal, debido a la accion de diferentes mediadores liberados por las terminaciones neuronales, incluyendo agonistas para los receptores N-metil-D-aspartato. Ademas de las vias ascendentes sensitivas, vias descendentes inhibitorias modulan la sensacion de dolor, incluyendo la participacion de a2-agonistas localizados en los aferentes primarios y en la medula espinal. Este estudio viso evaluar el efecto antinociceptivo de la cetamina (antagonista del receptor N-metil-D-aspartato) y de la clonidina (a2-agonista) administrada por via peridural, en el tratamiento de dolor cronico neuropatico. METODO: Veintiseis pacientes adultos con queja de dolor tipo neuropatico, no-responsivo a los tratamientos convencionales, fueron de forma prospectiva, aleatoria y duplamente encubierta, divididos en dos grupos. Todos los pacientes hicieron uso de 50-75 mg de amitriptilina por via oral diariamente. El dolor fue evaluado utilizandose la escala analogica visual (EAV) de 10 cm, en que “cero” correspondio a “ausencia de dolor” y “diez” a “peor dolor imaginable”. Un cateter peridural fue introducido en la region lumbar, y las medicaciones por via peridural fueron administradas en intervalos de 8 horas, durante tres semanas. El Grupo Cetamina recibio 0,1 mg.kg-1 de cetamina sin conservante, seguida de la administracion de 30 mg de lidocaina a 1%, en cada aplicacion. El Grupo Clonidina recibio 30 µg de clonidina sin conservante, seguida de la administracion de 30 mg de lidocaina a 1%, en cada aplicacion. RESULTADOS: Veintitres pacientes hicieron parte de la evaluacion final. La administracion de cetamina o clonidina por via peridural, en las dosis propuestas, resulto en analgesia durante todo el periodo de la manutencion del cateter peridural (EAV inicial 8-10 cm versus EAV final 0-3 cm) (p < 0,002). Despues de la retirada del cateter peridural, los valores numericos de la EAV se mantuvieron entre 0-3 cm durante 2 a 5 semanas. CONCLUSIONES: La administracion de cetamina o clonidina por via peridural resulto en accion antinociceptiva en pacientes con dolor cronico neuropatico, no-responsivo a los tratamientos convencionales, representando alternativas eficaces, cuando el tratamiento convencional no obtuvo suceso.

Fatal Recrudescence of Malignant Hyperthermia in an Infant with Moebius Syndrome

BACKGROUND AND OBJECTIVES Malignant hyperthermia (MH) is a pharmacogenetic skeletal muscle disorder characterized by a hypermetabolic state after anesthesia with succinylcholine and/ or volatile anesthetics. Various neuromuscular syndromes are associated with susceptibility; however, Moebius syndrome has not been reported. Dantrolene is the drug of choice for treatment. Recurrence may occur in up to 20% of cases after the initial event treatment. CASE REPORT Male infant, fi rst twin, 7 months old, weighing 6.5kg and presenting with Moebius syndrome was admitted for clubfoot repair. The patient had MH after exposure to sevoflurane and succinylcholine, which was readily reversed with dantrolene maintained for 24 hours. Ten hours after dantrolene discontinuation, there was recrudescence of MH that did not respond satisfactorily to treatment, and the patient died. DISCUSSION Musculoskeletal disorders in children are associated with increased risk of developing MH, although Moebius syndrome has not yet been reported. Dantrolene is the drug of choice for treating this syndrome; prophylaxis is indicated during the fi rst 24-48 hours of the episode onset. The main risk factors for recurrence are muscular type, long latency after anesthetic exposure, and increased temperature. The child had only one risk factor. This case leads us to reflect on how we must be attentive to children with musculoskeletal disease and maintain treatment for 48 hours.

Avaliação dos efeitos cognitivos da indução inalatória com sevoflurano com ou sem associação com óxido nitroso: estudo comparativo em adultos voluntários

JUSTIFICATIVA E OBJETIVOS: A inducao com agentes inalatorios via mascara facial vem sendo alvo de crescente interesse desde a introducao do sevoflurano. Ao mesmo tempo a influencia da adicao de oxido nitroso merece atencao no que diz respeito ao padrao da inducao e da recuperacao, sobretudo, a completa recuperacao da funcao cognitiva. O objetivo deste estudo foi avaliar os efeitos cognitivos da inducao anestesica inalatoria com sevoflurano de modo isolado ou associado ao oxido nitroso em adultos. METODO: Foram estudados 20 voluntarios adultos, estado fisico ASA I, sem doenca psiquiatrica ou utilizacao previa de benzodiazepinicos. Apos terem sido submetidos ao questionario Mini Exame do Estado Mental (MEEM), o Grupo I recebeu sevoflurano na concentracao de 5% ate que fosse atingido o indice bispectral (BIS) de 60. O Grupo II recebeu oxido nitroso em concentracoes crescentes com incremento de 10 ate 50% quando entao foi administrado o sevoflurano ate que fosse atingido o BIS de 60. Foram anotados valores de pressao arterial, frequencia cardiaca, oximetria de pulso, SEF 95% (Spectral Edge Frequency), tempo de inducao e o tempo de recuperacao anestesica. RESULTADOS: Nao houve diferenca entre o tempo de inducao nos dois grupos. O Grupo II apresentou maior estabilidade hemodinâmica e menor valor do SEF 95% no momento BIS = 60. O tempo para recuperacao da funcao cognitiva foi igual nos dois grupos, assim como a incidencia de nauseas e vomitos. Nao foi verificada ocorrencia de apneia. O Grupo II apresentou maior incidencia de agitacao psicomotora durante a inducao. CONCLUSOES: O sevoflurano isoladamente ou em associacao com oxido nitroso constituiu opcao adequada para inducao inalatoria ou sedacao ambulatorial em adultos, com manutencao da ventilacao espontânea, proporcionando rapida recuperacao da funcao cognitiva.BACKGROUND AND OBJECTIVES Anesthetic induction with inhalational agents using a facemask has gained attention since the introduction of sevoflurane. At the same time, the influence of adding nitrous oxide on the pattern of induction and recuperation deserves attention, especially regarding recovery of the cognitive function. The objective of this study was to evaluate the cognitive effects of inhalational anesthetic induction with sevoflurane alone or associated with nitrous oxide in adults. METHODS Twenty adult volunteers, ASA physical state I, without a history of psychiatric disorders or prior use of benzodiazepines, were enrolled in the study. After answering the Mini-Mental State Examination (MMSE), Group I received 5% sevoflurane until a bispectral index (BIS) of 60 was achieved. Group II received nitrous oxide in increments of 10% until it achieved 50% followed by the administration of sevoflurane until a BIS of 60 was achieved. Arterial blood pressure, heart rate, pulse oxymetry, SEF 95% (Spectral Edge Frequency), induction time, and anesthetic recovery time were evaluated. RESULTS Time of induction showed no differences between both groups. Group II showed greater hemodynamic stability and smaller SEF 95% values when BIS achieved 60. The time for recovery of cognitive function was similar in both groups, as well as the incidence of nausea and vomiting. There were no cases of apnea. Group II demonstrated greater incidence of psychomotor agitation during induction. CONCLUSIONS Sevoflurane alone or in association with nitrous oxide is an adequate option for inhalational anesthetic induction or outpatient sedation in adults, maintaining spontaneous ventilation, and providing a fast recuperation of the cognitive function.

Efeitos da adição do óxido nitroso na anestesia durante pneumoperitônio em intervenção cirúrgica videolaparoscópica

BACKGROUND AND OBJECTIVES The use of pneumoperitoneum during videolaparoscopic surgeries activates neuroendocrine mechanisms, and causes cardiovascular and hormonal changes. The aim of this study was to evaluate the effects of the addition of nitrous oxide, to maintain adequate anesthetic levels, on the cardiovascular sympathetic response and in the expired concentration of sevoflurane (ECsevo) during pneumoperitoneum, by evaluating hemodynamic parameters, BIS, and SEF95%, during videolaparoscopic cholecystectomies. METHODS Thirty-one patients, physical status ASA I and II, ages 19 to 76 years, were included in the study. Anesthetic induction was accomplished with sufentanyl 0.3 microg kg(-1)), propofol (2.5 mg kg(-1)), and cisatracurium (0.15 mg kg(-1)). During the maintenance phase of anesthesia, the dose of ECsevo was adjusted to maintain BIS between 40 and 60. The administration of increasing concentrations of nitrous oxide, 20%, 40%, and 60%, was initiated after inducing pneumoperitoneum. The bispectral index, SEF95%, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were evaluated at M1 - 5 minutes after the pneumoperitoneum; M2 - when the expired concentration of N2O = 20% (ECN2O = 20%); M3 - ECN2O = 40%; M4 - ECN2O = 60%. RESULTS There were no significant differences among SBP, DBP, MAP, and HR in the moments studied. There was a significant difference in ECsevo in those same moments, with a 35% reduction when M1 and M4 were compared. CONCLUSIONS When nitrous oxide is administered in association with sevoflurane during pneumoperitoneum in videolaparoscopic cholecystectomy, it provides for hemodynamic stability and reduces the amount of sevoflurane needed while, at the same time, maintaining electroencephalographic parameters compatible with adequate anesthesia.BACKGROUND AND OBJECTIVES: The use of pneumoperitoneum during videolaparoscopic surgeries activates neuroendocrine mechanisms, and causes cardiovascular and hormonal changes. The aim of this study was to evaluate the effects of the addition of nitrous oxide, to maintain adequate anesthetic levels, on the cardiovascular sympathetic response and in the expired concentration of sevoflurane (ECsevo) during pneumoperitoneum, by evaluating hemodynamic parameters, BIS, and SEF95%, during videolaparoscopic cholecystectomies. METHODS: Thirty-one patients, physical status ASA I and II, ages 19 to 76 years, were included in the study. Anesthetic induction was accomplished with sufentanyl 0.3 µg.kg-1), propofol (2.5 mg.kg-1), and cisatracurium (0.15 mg.kg-1). During the maintenance phase of anesthesia, the dose of ECsevo was adjusted to maintain BIS between 40 and 60. The administration of increasing concentrations of nitrous oxide, 20%, 40%, and 60%, was initiated after inducing pneumoperitoneum. The bispectral index, SEF95%, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) were evaluated at M1 - 5 minutes after the pneumoperitoneum; M2 - when the expired concentration of N2O = 20% (ECN2O = 20%); M3 - ECN2O = 40%; M4 - ECN2O = 60%. RESULTS: There were no significant differences among SBP, DBP, MAP, and HR in the moments studied. There was a significant difference in ECsevo in those same moments, with a 35% reduction when M1 and M4 were compared. CONCLUSIONS: When nitrous oxide is administered in association with sevoflurane during pneumoperitoneum in videolaparoscopic cholecystectomy, it provides for hemodynamic stability and reduces the amount of sevoflurane needed while, at the same time, maintaining electroencephalographic parameters compatible with adequate anesthesia.

Avaliação hemodinâmica e metabólica da infusão contínua de dexmedetomidina e de remifentanil em colecistectomia videolaparoscópica: estudo comparativo

BACKGROUND AND OBJECTIVES Dexmedetomidine has been used for sedation and as coadjuvant drug in general anesthesia. This study aimed at evaluating cardiovascular and sympathetic-adrenal responses to tracheal intubation and pneumoperitoneum inflation with dexmedetomidine, as compared to remifentanil during anesthesia with sevoflurane for videolaparoscopic cholecystectomy. METHODS Forty two physical status ASA I or II patients, aged 25 to 55 years, were randomly distributed in two groups: GI and GII. Anesthesia was induced with 1 microg.kg-1 dexmedetomidine (GI) or remifentanil (GII) continuous infusion for 10 minutes, followed by propofol and cisatracurium. Anesthesia was maintained with 0.7 microg.kg-1.h-1 dexmedetomidine or 0.5 microg.kg-1.h-1 remifentanil continuous infusion and different sevoflurane concentrations. SBP, DBP and HR were recorded in the following moments: M1 - before initial drug infusion; M2 - after end of initial drug infusion; M3 - after tracheal intubation; M4 - before pneumoperitoneum; M5 - after pneumoperitoneum; M6 - five minutes after pneumoperitoneum deflation; M7 - after tracheal extubation. Epinephrine and norepinephrine were dosed in M4, M5 and M6. Sevoflurane expired concentration (EC), EC/MAC ratio and sevoflurane consumption were recorded in M4, M5 and M6. RESULTS SBP and DBP variations were higher in the dexmedetomidine group in M4 and M5. HR, epinephrine and norepinephrine levels were similar between groups. Sevoflurane EC was higher in M4 and M6 for GI, as well as EC/MAC ratio. There has been a higher sevoflurane consumption in GI, with a trend to less analgesics and anti-emetics consumption. CONCLUSIONS In the conditions of our study, dexmedetomidine has inhibited catecholamine release during tracheal intubation and pneumoperitoneum, however, has not prevented blood pressure increase in response to peritoneal inflation.JUSTIFICATIVA Y OBJETIVOS: La dexmedetomidina ha sido utilizada para sedacion y como coadjuvante en anestesia general. El objetivo de este estudio fue evaluar la respuesta cardiovascular y simpatico-adrenal a la intubacion traqueal y la insuflacion del pneumoperitoneo, comparandola al remifentanil durante anestesia con sevoflurano para colecistectomia videolaparoscopica. METODO: Fueron incluidos en el estudio 42 pacientes, estado fisico ASA I o II, con edades entre 25 y 55 anos, distribuidos aleatoriamente en dos grupos: GI y GII. La induccion de la anestesia fue realizada con infusion continua de 1 µg.kg-1 de dexmedetomidina (GI) o remifentanil (GII), durante 10 minutos, seguido de propofol y cisatracurio. La manutencion de la anestesia fue realizada con la infusion continua de 0,7 µg.kg-1.h-1 de dexmedetomidina o 0,5 µg.kg-1.h-1 de remifentanil y concentraciones variadas de sevoflurano. Fueron anotadas la PAS, PAD y FC en los momentos: M1 - antes del inicio de la infusion inicial de la droga; M2 - despues del termino de la infusion inicial de la droga; M3 - despues de la intubacion orotraqueal; M4 - antes del inicio del pneumoperitoneo; M5 - despues del pneumoperitoneo; M6 - cinco minutos despues desinsuflado el pneumoperitoneo, M7 - despues extubacion traqueal. En M4, M5 y M6 fueron dosadas adrenalina y noradrenalina. La concentracion expirada (CE) del sevoflurano, la relacion CE/CAM, consumen de sevoflurano fueron registrados en M4, M5 y M6. RESULTADOS: Variaciones en la PAS y PAD fueron mayores en el grupo de la dexmedetomidina en M4 y M5. A FC y los niveles de adrenalina y noradrenalina no presentaron diferencia entre los grupos. La CE del sevoflurano fue mayor en M4 y M6 en el GI, asi como la CE/CAM. En el GI, el consumen de sevoflurano fue mayor y se observo una tendencia para menor consumen de analgesicos y antiemeticos. CONCLUSIONES: En las condiciones de este estudio, la dexmedetomidina inhibio la liberacion de catecolaminas durante la intubacion orotraqueal y el pneumoperitoneo, sin embargo, no impidio el aumento de la presion arterial en respuesta a la insuflacion peritoneal.

Epidural ketamine versus epidural clonidine as therapeutic for refractory neuropathic chronic pain

BACKGROUND AND OBJECTIVES: Chronic pain results in an increased response of spinal cord dorsal horn neurons due to the action of several mediators released by neuronal terminals, including the agonists of N-methyl-D-aspartate receptors. In addition to sensory ascending pathways, inhibitory descending pathways modulate pain, including a2-adrenoceptors located on primary afferent terminals and on the spinal cord. This study was designed to investigate the anti-noxious effects of epidural ketamine (N-methyl-D-aspartate antagonist) or epidural clonidine (a2-adrenergic agonist) in the treatment of neuropathic chronic pain. METHODS: Twenty-six adult patients, with neuropathic chronic pain not responsive to conservative therapy, were randomly divided into two groups in this prospective double-blind study. All patients were regularly taking 50-75 mg oral amitriptyline at bedtime. Pain was evaluated through a 10 cm visual analog scale (VAS), with “zero” corresponding to “no pain” and 10 to “the worst possible pain”. A lumbar epidural catheter was inserted and test drugs were administered at 8 hour-intervals during 3 weeks. The ketamine group (KG) was given each time 1 mg.kg-1 preservative-free ketamine followed by 30 mg of 1% lidocaine. The clonidine group (Clo G) was given 30 µg preservative-free clonidine followed by 30 mg of 1% lidocaine (3 ml). RESULTS: Twenty-three patients were evaluated (KG-n=10; Clo G-n=13). Epidural administration of ketamine or clonidine in the proposed doses resulted in analgesia during epidural catheter maintenance (initial VAS 8-10 cm versus final VAS 0-3 cm) (p < 0.002). VAS scores remained maintained between 0 and 3 cm from 2 to 5 weeks following epidural catheter removal. CONCLUSIONS: Epidural ketamine or clonidine resulted in analgesia for neuropathic chronic pain refractory to conservative treatment and are effective alternatives when conventional treatment fails.JUSTIFICATIVA Y OBJETIVOS: El dolor cronico resulta en respuesta aumentada de los neuronios del cuerno dorsal de la medula espinal, debido a la accion de diferentes mediadores liberados por las terminaciones neuronales, incluyendo agonistas para los receptores N-metil-D-aspartato. Ademas de las vias ascendentes sensitivas, vias descendentes inhibitorias modulan la sensacion de dolor, incluyendo la participacion de a2-agonistas localizados en los aferentes primarios y en la medula espinal. Este estudio viso evaluar el efecto antinociceptivo de la cetamina (antagonista del receptor N-metil-D-aspartato) y de la clonidina (a2-agonista) administrada por via peridural, en el tratamiento de dolor cronico neuropatico. METODO: Veintiseis pacientes adultos con queja de dolor tipo neuropatico, no-responsivo a los tratamientos convencionales, fueron de forma prospectiva, aleatoria y duplamente encubierta, divididos en dos grupos. Todos los pacientes hicieron uso de 50-75 mg de amitriptilina por via oral diariamente. El dolor fue evaluado utilizandose la escala analogica visual (EAV) de 10 cm, en que “cero” correspondio a “ausencia de dolor” y “diez” a “peor dolor imaginable”. Un cateter peridural fue introducido en la region lumbar, y las medicaciones por via peridural fueron administradas en intervalos de 8 horas, durante tres semanas. El Grupo Cetamina recibio 0,1 mg.kg-1 de cetamina sin conservante, seguida de la administracion de 30 mg de lidocaina a 1%, en cada aplicacion. El Grupo Clonidina recibio 30 µg de clonidina sin conservante, seguida de la administracion de 30 mg de lidocaina a 1%, en cada aplicacion. RESULTADOS: Veintitres pacientes hicieron parte de la evaluacion final. La administracion de cetamina o clonidina por via peridural, en las dosis propuestas, resulto en analgesia durante todo el periodo de la manutencion del cateter peridural (EAV inicial 8-10 cm versus EAV final 0-3 cm) (p < 0,002). Despues de la retirada del cateter peridural, los valores numericos de la EAV se mantuvieron entre 0-3 cm durante 2 a 5 semanas. CONCLUSIONES: La administracion de cetamina o clonidina por via peridural resulto en accion antinociceptiva en pacientes con dolor cronico neuropatico, no-responsivo a los tratamientos convencionales, representando alternativas eficaces, cuando el tratamiento convencional no obtuvo suceso.

A Clinical Experimental Model to Evaluate Analgesic Effect of Remote Ischemic Preconditioning in Acute Postoperative Pain

This study aims to evaluate the viability of a clinical model of remote ischemic preconditioning (RIPC) and its analgesic effects. It is a prospective study with twenty (20) patients randomly divided into two groups: control group and RIPC group. The opioid analgesics consumption in the postoperative period, the presence of secondary mechanical hyperalgesia, the scores of postoperative pain by visual analog scale, and the plasma levels interleukins (IL-6) were evaluated. The tourniquet applying after spinal anesthetic block was safe, producing no pain for all patients in the tourniquet group. The total dose of morphine consumption in 24 hours was significantly lower in RIPC group than in the control group (p = 0.0156). The intensity analysis of rest pain, pain during coughing and pain in deep breathing, showed that visual analogue scale (VAS) scores were significantly lower in RIPC group compared to the control group: p = 0.0087, 0.0119, and 0.0015, respectively. There were no differences between groups in the analysis of presence or absence of mechanical hyperalgesia (p = 0.0704) and in the serum levels of IL-6 dosage over time (p < 0.0001). This clinical model of remote ischemic preconditioning promoted satisfactory analgesia in patients undergoing conventional cholecystectomy, without changing serum levels of IL-6.