Nubia Verçosa

Depressão em pacientes com dor no câncer avançado

BACKGROUND AND OBJECTIVES The importance of emotional symptoms in the context of the health-disease binomium, and efforts to spread information on Palliative Medicine motivated this article. The objective of this literature review was to propose a reflection on the diagnosis of depression in patients with advanced cancer with pain, based on existing concepts and definitions. CONTENTS Pain and depression are prevalent symptoms in cancer patients. Considering the different points of intersection between physical and mental diseases, sometimes the diagnosis of depression in patients with cancer and pain is difficult. This datum is very important because depression decreases considerably the quality of life of patients, and should be diagnosed and treated properly CONCLUSIONS After reviewing the literature, a few questions remained unanswered. This fact awakens the interest to undertake studies that propose precise diagnostic solutions and efficient treatment of this symptom in patients with advanced cancer.BACKGROUND AND OBJECTIVES: The importance of emotional symptoms in the context of the health-disease binomium, and efforts to spread information on Palliative Medicine motivated this article. The objective of this literature review was to propose a reflection on the diagnosis of depression in patients with advanced cancer with pain, based on existing concepts and definitions. CONTENTS: Pain and depression are prevalent symptoms in cancer patients. Considering the different points of intersection between physical and mental diseases, sometimes the diagnosis of depression in patients with cancer and pain is difficult. This datum is very important because depression decreases considerably the quality of life of patients, and should be diagnosed and treated properly. CONCLUSIONS: After reviewing the literature, a few questions remained unanswered. This fact awakens the interest to undertake studies that propose precise diagnostic solutions and efficient treatment of this symptom in patients with advanced cancer.

Análise clínica e terapêutica dos pacientes oncológicos atendidos no programa de dor e cuidados paliativos do Hospital Universitário Clementino Fraga Filho no ano de 2003

JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos tem como meta principal o controle da dor e de outros sintomas nos pacientes com doencas cronicas, sem possibilidade de cura, sobretudo no câncer avancado. A dor intensa acomete 75% dos pacientes com câncer avancado, interferindo na qualidade de vida e segundo a OMS e considerada uma emergencia medica mundial. Este estudo avaliou o perfil dos pacientes oncologicos do Programa de Tratamento da Dor Cronica e Cuidados Paliativos do HUCFF/FM/UFRJ, ressaltando a atuacao do anestesiologista, as medicacoes utilizadas, a humanizacao do tratamento e a melhor qualidade de vida do paciente. METODO: Retrospectivamente, foram analisados os prontuarios dos pacientes oncologicos no ano de 2003. Destacaram-se os parâmetros: idade, raca, sexo, doencas preexistentes, orgao de origem do câncer, tipo de dor e outros sintomas, medicacoes utilizadas, rotinas hospitalares e o termino do tratamento. RESULTADOS: Os tipos de dor encontrados foram nociceptiva, neuropatica e incidental, avaliadas utilizando-se a escala unidimensional de faces. Verificou-se a analgesia controlada pelo paciente (PCA) com metadona, via oral, em ambiente domiciliar na 1a semana. Apos esse periodo, o paciente retornava ao ambulatorio para o calculo da dose regular da metadona. Outros opioides utilizados foram codeina, tramadol, morfina e oxicodona. Alem da dor, os pacientes apresentaram: constipacao, nauseas, vomitos, delirium, alteracao do sono e dispneia. Os neurolepticos, corticoides e laxantes foram usados como farmacos adjuvantes. CONCLUSOES: A analgesia controlada pelo paciente utilizando a metadona mostrou-se segura e eficaz pela nao-ocorrencia de efeitos colaterais significativos. O conhecimento clinico e farmacologico do anestesiologista na equipe multiprofissional proporcionou melhor atendimento para o alivio dos sintomas dos pacientes e humanizacao no periodo final de vida.

Depression in patients with advanced cancer and pain

BACKGROUND AND OBJECTIVES The importance of emotional symptoms in the context of the health-disease binomium, and efforts to spread information on Palliative Medicine motivated this article. The objective of this literature review was to propose a reflection on the diagnosis of depression in patients with advanced cancer with pain, based on existing concepts and definitions. CONTENTS Pain and depression are prevalent symptoms in cancer patients. Considering the different points of intersection between physical and mental diseases, sometimes the diagnosis of depression in patients with cancer and pain is difficult. This datum is very important because depression decreases considerably the quality of life of patients, and should be diagnosed and treated properly CONCLUSIONS After reviewing the literature, a few questions remained unanswered. This fact awakens the interest to undertake studies that propose precise diagnostic solutions and efficient treatment of this symptom in patients with advanced cancer.BACKGROUND AND OBJECTIVES: The importance of emotional symptoms in the context of the health-disease binomium, and efforts to spread information on Palliative Medicine motivated this article. The objective of this literature review was to propose a reflection on the diagnosis of depression in patients with advanced cancer with pain, based on existing concepts and definitions. CONTENTS: Pain and depression are prevalent symptoms in cancer patients. Considering the different points of intersection between physical and mental diseases, sometimes the diagnosis of depression in patients with cancer and pain is difficult. This datum is very important because depression decreases considerably the quality of life of patients, and should be diagnosed and treated properly. CONCLUSIONS: After reviewing the literature, a few questions remained unanswered. This fact awakens the interest to undertake studies that propose precise diagnostic solutions and efficient treatment of this symptom in patients with advanced cancer.

Effects of magnesium sulphate on the pharmacodynamics of rocuronium in patients aged 60 years and older: A randomised trial.

BACKGROUND There is little information on the interaction between magnesium sulphate (MgSO4) and rocuronium in elderly patients. With a growing number of older patients who need surgical procedures, it is increasingly important to study this age group. OBJECTIVE To evaluate the effects of MgSO4 administration on the pharmacodynamics of rocuronium in patients aged 60 years or older. DESIGN A randomised controlled trial. SETTING A tertiary care hospital. PATIENTS Sixty-four patients, aged 60 years or older, American Society of Anesthesiologists (ASA) physical status classes I to III, scheduled for elective oncological head and neck surgery. Exclusion criteria were severe renal insufficiency (calculated creatinine clearance <30 ml min−1), preoperatorive serum magnesium concentration of more than 1.25 mmol l−1 and patients receiving drugs known to affect neuromuscular function. INTERVENTIONS Patients were randomly allocated to one of two groups: in the magnesium group, patients received MgSO4 30 mg kg−1 intravenously, for 10 min, and then a continuous intravenous infusion at a rate of 1 g h−1. The control group received the same volume of physiological saline. Neuromuscular function was evaluated continuously in both groups. MAIN OUTCOME MEASURES Total recovery time was the primary outcome. Onset time, clinical duration, recovery index and recovery time were considered as secondary endpoints. Values are given as mean [SD]. RESULTS Total recovery time from neuromuscular block (NMB) was 113 [36] min in the magnesium group and 101 [39] min in the control group. Clinical duration was 69 [23] min in the magnesium group and 59 [28] min in the control group. Recovery index was 19 [36] min in the magnesium group and 17 [6] min in the control group. Recovery time was 44 [22] min in the magnesium group and 42 [18] min in the control group. There were no statistically significant differences between the groups in any of the recovery indices. In the magnesium group, the mean onset time was 144 [58] s, significantly shorter than the onset time in the group that received physiological saline, which was 187 [90] s (P = 0.03). Group variances were compared using an F test: onset time varied significantly less in the magnesium group (P = 0.02). CONCLUSION In oncology patients of 60 or more years of age, preadministration of MgSO4, with the doses used in this study, significantly reduced the onset time of NMB induced by rocuronium. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01804205.

Controle da dor pós-operatória da artroplastia total do joelho: é necessário associar o bloqueio do nervo isquiático ao bloqueio do nervo femoral?

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.BACKGROUND AND OBJECTIVES Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.

A Randomized Blinded Study of the Left Ventricular Myocardial Performance Index Comparing Epinephrine to Levosimendan following Cardiopulmonary Bypass.

Background The objective was to evaluate the effect of epinephrine and levosimendan on the left ventricle myocardial performance index in patients undergoing on-pump coronary artery by-pass grafting (CABG). Methods In a double-blind, randomized clinical trial, 81 patients (age: 45–65 years) of both genders were randomly divided to receive either epinephrine at a dosage of 0.06 mcg.kg1.min-1 (epinephrine group, 39 patients) or levosimendan at 0.2 mcg.kg1.min-1 (levosimendan group, 42 patients) during the rewarming of cardiopulmonary by-pass (CPB). Hemodynamic data were collected 30 minutes after tracheal intubation, before chest open (pre-CPB) and 10 minutes after termination of protamine (post-CPB). As the primary outcome, we evaluated the left ventricle myocardial performance index by the Doppler echocardiography. The myocardial performance index is the sum of the isovolumetric contraction time and the isovolumetric relaxation time, divided by the ejection time. Secondary outcomes were systolic and diastolic evaluations of the left ventricle and postoperative troponin I and MB-CK levels. Results Of the 81 patients allocated to the research, we excluded 2 patients in the epinephrine group and 6 patients in the levosimendan group because they didn’t wean from CPB in the first attempt. There was no statistical difference between the groups in terms of patient characteristics, risk factors, or CPB time. The epinephrine group had a lower left ventricle myocardial performance index (p = 0.0013), higher cardiac index (p = 0.03), lower systemic vascular resistance index (p = 0.01), and higher heart rate (p = 0.04) than the levosimendan group at the post-CPB period. There were no differences between the groups in diastolic dysfunction. The epinephrine group showed higher incidence of weaning from CPB in the first attempt (95% vs 85%, p = 0.0001) when compared to the levosimendan group and the norepinephrine requirement was higher in the levosimenandan group than epinephrine group (16% vs. 47%; p = 0.005) in post-CPB period. Twenty-four hours after surgery, the plasma levels of troponin I (epinephrine group: 4.5 ± 5.7 vs. levosimendan group: 2.5 ± 3.2 g/dl; p = 0.09) and MB-CK (epinephrine group: 50.7 ± 31 vs. levosimendan group: 37 ± 17.6 g/dl; p = 0.08) were not significantly different between the two groups. Conclusion When compared to levosimendan, patients treated with epinephrine had a lower left ventricle myocardial performance index in the immediate post-CPB period, encouraging an efficient weaning from CPB in patients undergoing on-pump CABG. Trial Registration ClinicalTrials.gov NCT01616069

Control of postoperative pain following total knee arthroplasty: is it necessary to associate sciatic nerve block to femoral nerve block?

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.BACKGROUND AND OBJECTIVES Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.

A study on electrocardiographic changes secondary to the use of tricyclic antidepressants in patients with chronic pain

BACKGROUND AND OBJECTIVES Tricyclic antidepressants (TCAs) are widely used as analgesics in chronic lumbar pain and neuropathic pain. The objective of this study was to evaluate the electrocardiographic changes in patients with chronic pain treated with amitriptyline or imipramine. METHODS Forty patients, ages 26 to 81 years (57.27 +/- 13.65 years) of both genders (female 19, male 21), with neuropathic syndromes (lumbosciatalgia, postlaminectomy syndromes, and postherpetic neuritis, among others) participated in this study; 60% had cardiovascular diseases; 30% had changes in the ECG (RBBB, LBBB, first-degree AVB, LAHB, or PVCs). Three ECGs were done in each patient: one ECG was done before beginning treatment, and 30 and 60 days after beginning treatment evaluating PR, QRS, QT QTc, DQT DQTc, and HR. Thirty-two patients were on amitriptyline and eight on imipramine. The mean dose at the end of the study was 54.29 mg of amitriptyline and 46.87 mg of imipramine. RESULTS Analysis of electrocardiographic parameters after the use of TCAs showed that amitriptyline caused a transitory increase in heart rate in females (p = 0.049), and the duration of the QRS in patients 60 years or older and patients with cardiopathies (p = 0.01). In patients who received 75 mg of amitriptyline, the QTc interval was greater when compared to that of patients who received 25 mg of the drug (p = 0.0044). The increase in those parameters demonstrated the effects of amitriptyline on cardiac conduction; however, clinical compromise was not seen, since they remained within normal limits (QRS < 110 msec and QTc < 470 msec). CONCLUSIONS The chronic use of TACs proved to be safe and effective, and it did not show changes in cardiac conduction with clinical repercussion.JUSTIFICATIVA Y OBJETIVOS: Los antidepresivos triciclicos (ADT) son muy utilizados como analgesicos para lumbalgias cronicas y dolores neuropaticos. El objetivo de este estudio fue evaluar las alteraciones electrocardiograficas de los pacientes con dolor cronico que usan amitriptilina o imipramina. METODO: Se estudiaron 40 pacientes con edad entre 26 y 81 anos (m = 57,27 ± 13,65 anos), de los dos sexos (mujeres 19, hombres 21), con sindromes neuropaticos (lumbociatalgias, sindromes pos-laminectomia, neuritis pos-herpetica, entre otras); un 60% con enfermedades cardiovasculares; 30% tenian ECG alterado (BRD, BRE, BAV 1°G, HBAE o extra-sistoles). Se realizaron y se analizaron tres ECGs: antes del inicio de los ADT, 30 y 60 dias despues del inicio del tratamiento, evaluando los parametros PR, QRS, QT, QTc, DQT, DQTc y FC. Treinta y dos pacientes usaron amitriptilina y ocho imipramina. La dosis promedio al final del estudio fue de 54,29 mg de amitriptilina y de 46,87 mg de imipramina. RESULTADOS: El analisis de las variables electrocardiograficas despues del uso de los ADT arrojo lo siguiente: la amitriptilina aumento la frecuencia cardiaca transitoriamente en el sexo femenino (p = 0,049) y la duracion del QRS en los pacientes con edad igual o superior a los 60 anos y en los cardiopatas en la segunda evaluacion (p = 0,01). En los pacientes que recibieron amitriptilina, dosis de 75 mg, el intervalo QTc fue mayor cuando se le comparo a las dosis de 25 mg (p = 0,0044). El aumento de esos parametros mostro el efecto de la amitriptilina sobre la conduccion cardiaca, sin embargo, no se registro comprometimiento clinico, pues los valores permanecieron dentro de los limites de la normalidad (QRS < 110ms y QTc < 470ms). CONCLUSIONES: El uso clinico de los ADT en dolores cronicos, arrojo resultados seguros y eficaces, y no presento disturbio de la conduccion cardiaca con repercusion clinica.

Clinical and therapeutic analysis of oncology patients treated at the pain and palliative care program of the Hospital Universitário Clementino Fraga Filho in 2003

JUSTIFICATIVA E OBJETIVOS: Os cuidados paliativos tem como meta principal o controle da dor e de outros sintomas nos pacientes com doencas cronicas, sem possibilidade de cura, sobretudo no câncer avancado. A dor intensa acomete 75% dos pacientes com câncer avancado, interferindo na qualidade de vida e segundo a OMS e considerada uma emergencia medica mundial. Este estudo avaliou o perfil dos pacientes oncologicos do Programa de Tratamento da Dor Cronica e Cuidados Paliativos do HUCFF/FM/UFRJ, ressaltando a atuacao do anestesiologista, as medicacoes utilizadas, a humanizacao do tratamento e a melhor qualidade de vida do paciente. METODO: Retrospectivamente, foram analisados os prontuarios dos pacientes oncologicos no ano de 2003. Destacaram-se os parâmetros: idade, raca, sexo, doencas preexistentes, orgao de origem do câncer, tipo de dor e outros sintomas, medicacoes utilizadas, rotinas hospitalares e o termino do tratamento. RESULTADOS: Os tipos de dor encontrados foram nociceptiva, neuropatica e incidental, avaliadas utilizando-se a escala unidimensional de faces. Verificou-se a analgesia controlada pelo paciente (PCA) com metadona, via oral, em ambiente domiciliar na 1a semana. Apos esse periodo, o paciente retornava ao ambulatorio para o calculo da dose regular da metadona. Outros opioides utilizados foram codeina, tramadol, morfina e oxicodona. Alem da dor, os pacientes apresentaram: constipacao, nauseas, vomitos, delirium, alteracao do sono e dispneia. Os neurolepticos, corticoides e laxantes foram usados como farmacos adjuvantes. CONCLUSOES: A analgesia controlada pelo paciente utilizando a metadona mostrou-se segura e eficaz pela nao-ocorrencia de efeitos colaterais significativos. O conhecimento clinico e farmacologico do anestesiologista na equipe multiprofissional proporcionou melhor atendimento para o alivio dos sintomas dos pacientes e humanizacao no periodo final de vida.

Impacto do ecocardiograma transesofágico intraoperatório na mortalidade em cirurgia de revascularização do miocárdio com circulação extracorpórea

OBJETIVO: avaliar as taxas de mortalidade e morbidade de doentes submetidos a revascularizacao do miocardio (RVM) com circulacao extracorporea (CEC) que utilizaram rotineiramente o ecocardiograma transesofagico intraoperatorio (ETEio). METODOS: estudo retrospectivo, observacional com avaliacao de prontuarios de 360 doentes no periodo entre abril de 2010 a abril de 2012. Foram analisados: idade, peso, altura sexo, EUROscore, diabete melito, fracao de ejecao e arterias acometidas. Os desfechos foram compilados no intra e no pos-operatorio (infarto do miocardio, acidente vascular cerebral, disfuncao renal, hemodialise, fibrilacao atrial, tempo de internacao no centro de tratamento intensivo). RESULTADOS: foram incluidos 53 doentes, com 27 recebendo a monitoracao. Foram excluidos 307 porque nao foram operados pela mesma equipe cirurgica. Os dois grupos foram homogeneos quanto a idade, peso e sexo, porem, a fracao ejecao foi menor no grupo que recebeu o ecotransesofagico (G ETEio: 56,3%; G Nao ETEio: 65,9% ± 11; p=0,01). Nos doentes em que nao foi utilizado o ETEio, a mortalidade foi maior (G ETEio: 0% e G Nao ETEio: 7,6%; p=0,01). Nao houve diferenca significativa entre os grupos quanto a incidencia de acidente vascular encefalico, infarto agudo do miocardio, fibrilacao atrial aguda e lesao renal. CONCLUSAO: a utilizacao do ecocardiograma transesofagico intraoperatorio em pacientes submetidos a revascularizacao do miocardio, com circulacao extracorporea, diminuiu a mortalidade perioperatoria; orientou quanto a utilizacao dos farmacos inotropicos e vasodilatadores e contribuiu para uma melhor evolucao dos doentes.