Dexmedetomidine As An Adjunct To Regional And Neuraxial Anesthesia

Regional and neuraxial anesthetic techniques are ever-expanding, and an understanding of the tools, medications, and adjuncts associated with these techniques is prudent for anesthesia providers. One goal of these techniques is to extend pain management beyond the initial surgical phase by using long-acting local anesthetics with or without adjunct medications. The purpose of this review is to detail the clinical utility, benefits, and risks of dexmedetomidine as an adjunct to regional and neuraxial anesthetic techniques. This review includes an analysis of literature of over 20 randomized controlled trials comparing the use of dexmedetomidine to other adjuncts in common regional and neuraxial techniques in adult patients. This expanding body of research suggests dexmedetomidine may exert desirable effects as an adjunct to regional and neuraxial anesthesia

The efficacy of continuous peripheral blocks after cardiothoracic surgery as evaluated by opioid use, pain, and recovery

Pain after cardiothoracic surgery is most intense the first postoperative days and for the most part mild to moderate. International guidelines recommend a multimodal analgesic strategy that includes local anesthetics for peripheral nerve blocks or local wound infiltration. However, for cardiothoracic surgery, there is a lack of evidence on (1) the best peripheral nerve block for minimally invasive and open procedures, (2) whether continuous nerve blocks are superior to single-shot blocks, and (3) if and what type of local anesthetic adjuncts should be used. Importantly, (4) the evaluation of the blocks should extend beyond the first 24 hours and include patient recorded outcome measures (PROMs). This thesis studied the efficacy of a continuous extrapleural block as part of a multimodal analgesic strategy after video-assisted thoracic surgery (VATS), whether the adjuncts sufentanil and adrenaline improved the analgesic effect of levobupivacaine in a continuous extrapleural block after VATS, and whether a continuous bilateral parasternal block with lidocaine reduced opioid requirement and improved recovery after sternotomy. In addition, the 3-month recovery after sternotomy was evaluated by means of an eHealth platform for repetitive Quality of Recovery (QoR)-15 scores and pain assessments. Study I showed that a continuous multiple-day infusion of levobupivacaine through a surgeon-inserted extrapleural catheter was a valid and safe part of a multimodal analgesic regimen after VATS. It also showed that VATS lobectomy was more painful than wedge resection. In Study II, levobupivacaine at 2.7 mg ml-1 and levobupivacaine at 1.25 mg ml-1 with the adjuncts sufentanil and adrenaline neither differed in 48- or 72-hour opioid requirement nor pain when infused extrapleurally at 5 ml.h-1 after VATS. Cumulative morphine doses of both treatment groups were low, and pain was overall mild. Infusion of 5 ml.h-1 levobupivacaine at 2.7 mg ml-1 (highest recommended daily dose) did not result in toxic serum concentrations, but it possibly resulted in superior analgesia in movement and improved recovery according to QoR-15 at 3 weeks postoperatively. Study III showed a postoperative 72-hour continuous bilateral parasternal block with lidocaine decreased morphine requirement with 65%. However, despite the well-controlled pain and the low 72-hour morphine dose, no improvement of recovery according to QoR-15 was seen. Neither did the systemic presence of lidocaine result in a decreased inflammatory response. Study IV showed an acceptable recovery as assessed by QoR-15 at 2 weeks after sternotomy for open heart surgery. The use of an eHealth platform for repetitive questionnaires was feasible. Age and the extent of surgery affected the questionnaire’s response rate

Topics in Regional Anesthesia

Regional anesthesia has progressively evolved and currently occupies a predominant place in our daily practice. The development of skills for the safe practice of regional anesthesia requires in-depth knowledge of anatomy, physiology, pharmacology, and the pathology of each patient candidate to receive some type of regional block, as well as special and prolonged training beyond residence, particularly in this era of the COVID-19 pandemic, during which the training of thousands of anesthesiology residents has been impaired. Undoubtedly, the benefits of regional anesthesia techniques are enormous, as are their complications. Countless guidelines for regional anesthesia have been described based on the classic anatomical recommendations, the search for paresthesias, neurostimulation, and medical images. The introduction of ultrasound guidance and the rational use of local anesthetics and their adjuvants have favorably revolutionized regional anesthesia, making it safer and more effective. This book addresses several contemporary topics in regional anesthesia in a variety of interesting clinical settings with practical importance

Equine clinics

The present final report concluding the degree of the Integrated Master in Veterinary Medicine at the University of Évora is based on the curricular externship in an outpatient clinic with Dr. An Sleeckx in the Greater Lisbon / Ribatejo area. This report is divided into two parts. The first part presents the casuistic of the externship and describes clinical cases like abdominal pain, lameness, pre-purchase exam, intoxication with monensin, insect bite hypersensitivity and castration which were followed during the externship. As painful events like lameness and colic are very common in equine clinics, a literature research on pain assessment in horses was made and presented in the second part as a monography. The focus was on new composite pain scales including behavior and facial expressions which seem to be the most reliable to detect pain according to the newest publications; Resumo: Clínica e Cirurgia de Equinos O presente relatório de conclusão do curso de Mestrado Integrado em Medicina Veterinária da Universidade de Évora é baseado no estágio curricular realizado em clínica ambulatória com a Dra. An Sleeckx na zona da Grande Lisboa/ Ribatejo. O relatório é dividido em duas partes. A primeira parte apresenta a casuística do estágio e descreve casos clínicos como dor abdominal, claudicações, acto de compra, intoxicação com monensina, hipersensibilidade à picada de insectos e castração, que foram acompanhados durante o estágio. Uma vez que eventos dolorosos como as claudicações e as cólicas são muito comuns nas clínicas equinas, foi feita uma pesquisa bibliográfica sobre avaliação da dor em cavalos, que foi apresentada na segunda parte como uma monografia. O foco foi em novas escalas composta de dor, incluindo comportamento e expressões faciais que parecem ser as mais fiáveis para detectar a dor de acordo com as mais recentes publicações

Eficacia de la infusión continua de levobupivacaína en la herida quirúrgica tras cesárea

Programa Oficial de Doutoramento en Ciencias da Saúde. 5007V01[Resumo] Algunhas pacientes aínda sofren dor tras unha cesárea. A infusión de anestésicos locais na ferida podería actuar sobre a sensibilización periférica e central. Avaliamos os beneficios da infusión continua de levobupivacaína tras cesárea na hiperalgesia secundaria e primaria, alivio da dor, dor persistente e resposta inflamatoria e metabólica de estrés. Setenta mulleres sas programadas para cesárea participaron neste ensaio prospectivo, aleatorizado, triplo-cego. As mulleres recibiron levobupivacaína 0,35%, 7 ml/ h durante 48h (Grupo L) ou solución salina (Grupo S). Recolléronse: hiperalgesia secundaria; hiperalgesia primaria; intensidade da dor posoperatorio; tempo ata o primeiro birlo de analgesia; dose acumulada de recate; dor persistente; parámetros bioquímicos; e eventos adversos. No Grupo L, a área de hiperalgesia secundaria reduciuse significativamente [43.4(18.5-80) fronte 68.4(39.0-136) cm2 e 45.1(0.9-89.8) fronte 67.3(31.3-175) cm2 ás 24 e 48 h, respectivamente; interacción grupo:tempo p< 0.001], o limiar de dor foi maior ás 24 h [633(441-802) fronte 417(300-572) g.mm-2, p=0.001], e o consumo de morfina foi menor ás 24 h [4(2-11) fronte 11(6-23), p= 0.003] fronte ao Grupo S. Os niveis de insulina foron significativamente máis baixos no Grupo L. A infusión de levobupivacaína na ferida podería ser un complemento antihiperalgésico eficaz.[Resumen] Algunas pacientes todavía sufren dolor tras una cesárea. La infusión de anestésicos locales en la herida podría actuar sobre la sensibilización periférica y central. Evaluamos los beneficios de la infusión continua de levobupivacaína tras cesárea en la hiperalgesia secundaria y primaria, alivio del dolor, dolor persistente y respuesta inflamatoria y metabólica de estrés. Setenta mujeres sanas programadas para cesárea participaron en este ensayo prospectivo, aleatorizado, triple-ciego. Las mujeres recibieron levobupivacaína 0,35%, 7 ml/h durante 48 h (Grupo L) o solución salina (Grupo S). Se recogieron: hiperalgesia secundaria; hiperalgesia primaria; intensidad del dolor posoperatorio; tiempo hasta el primer bolo de analgesia; dosis acumulada de rescate; dolor persistente; parámetros bioquímicos; y eventos adversos. En el Grupo L, el área de hiperalgesia secundaria se redujo significativamente [43.4(18.5-80) frente 68.4(39.0-136) cm2 y 45.1(0.9-89.8) frente 67.3(31.3-175) cm2 a las 24 y 48h, respectivamente; interacción grupo:tiempo p< 0.001], el umbral de dolor fue mayor a las 24h [633(441-802) frente 417(300-572) g.mm-2, p=0.001], y el consumo de morfina fue menor a las 24h [4(2-11) frente 11(6-23), p= 0.003] frente al Grupo S. Los niveles de insulina fueron significativamente más bajos en el Grupo L. La infusión de levobupivacaína en la herida podría ser un complemento antihiperalgésico eficaz.[Abstract] Some patients still report pain after cesarean delivery. Local anesthetic wound infusion might act on peripheral and central sensitization mechanisms. We evaluated the benefits of continuous wound infusion of levobupivacaine after cesarean delivery on secondary hyperalgesia and primary hyperalgesia, pain relief, persistent pain, and inflammatory and metabolic stress response. Seventy healthy women scheduled for cesarean delivery participated in this prospective, randomized, triple-blind trial. Women were randomized to receive continuous wound infusion (0.35% levobupivacaine 7 ml/h for 48 h; Group L) or saline (Group S). The following variables were collected: secondary hyperalgesia; primary hyperalgesia; intensity of postoperative pain; time to first bolus of patientcontrolled analgesia; cumulative dose of rescue morphine and acetaminophen; persistent postoperative pain; biochemical parameters; and adverse events. In Group L, the area of secondary hyperalgesia was significantly reduced [43.4(18.5-80) vs. 68.4(39.0-136) cm2 and 45.1(0.9-89.8) vs. 67.3(31.3-175) cm2 at 24 and 48 h, respectively; group:time interaction p-value < 0.001], the pain threshold was significantly higher at 24 hours [633(441-802) vs. 417(300-572) g.mm-2, p=0.001], and morphine consumption was significantly lower at 24 h [4(2-11) vs 11(6-23), p= 0.003] compared with Group S. Plasma insulin levels were significantly lower in Group L. Levobupivacaine wound infusion might be an effective antihyperalgesic adjunct

BLOQUEO DE PLEXO SUPRACLAVICULAR ECOGUIADO PARA ANALGESIA POSOPERATORIA USANDO ROPIVACAÍNA VS ROPIVACAÍNA CON DEXMEDETOMIDINA EN CIRUGÍAS DE MIEMBRO SUPERIOR EN EL H.G. JOSÉ VICENTE VILLADA, PERIODO MARZO A OCTUBRE 2020.

La dexmedetomidina es un agonista de los receptores α-2 con propiedades analgésicas y sedantes. Se utilizó dexmedetomidina junto con ropivacaína para realizar un bloqueo de plexo supraclavicular ecoguiado. Diversos adyuvantes junto a la ropivacaína han mostrado resultados prometedores en la prolongación de la duración de la analgesia en el bloqueo del plexo braquial, pero pocos estudios han evaluado estos efectos específicamente con la dexmedetomidina en el bloqueo de plexo supraclavicular ecoguiado.UAEM, el autor

Τυχαιοποιημένη, διπλή τυφλή, προοπτική μελέτη της αποτελεσματικότητας του αμφοτερόπλευρου αποκλεισμού της περιτονίας του ορθωτή μυός της ράχης υπό υπερηχογραφική καθοδήγηση, σε λαπαροσκοπικές χολοκυστεκτομές.

Σκοπός: Η λαπαροσκοπική χολοκυστεκτομή είναι μία από τις πιο συχνές χειρουργικές επεμβάσεις που πραγματοποιούνται από του γενικούς χειρουργούς. Αν και πραγματοποιείται με ελάχιστα επεμβατικές τεχνικές, ο μετεγχειρητικός πόνος των ασθενών μπορεί να είναι μέτριος έως και σοβαρός και να απαιτεί τη χορήγηση μεγάλων δόσεων οπιοειδών περιεγχειρητικά, σε συνδυασμό με άλλες κατηγορίες αναλγητικών παραγόντων προκειμένου να αντιμετωπιστεί. Ο αμφοτερόπλευρος αποκλεισμός της περιτονίας του ορθωτή μυός της ράχης [Erector Spinae Plane block (ESPB)] είναι ένας καινοτόμος περιφερικός αποκλεισμός του κορμού, ο οποίος πραγματοποιείται ως μέθοδος μετεγχειρητικής αναλγησίας σε μια σειρά από χειρουργικές επεμβάσεις. Το αναλγητικό αποτέλεσμα του ESPB στις λαπαροσκοπικές χολοκυστεκτομές δεν έχει αποδειχθεί ακόμη. Σκοπός της μελέτης είναι η εξερεύνηση της αποτελεσματικότητας του ESPB ως μιας περιεγχειρητικής μεθόδου αναλγησίας, στους ασθενείς που υποβάλλονται σε προγραμματισμένη χολοκυστεκτομή. Υλικά και Μέθοδος: Πρόκειται για μια τυχαιοποιημένη, διπλή τυφλή, προοπτική μελέτη. Εξήντα ασθενείς τυχαιοποιήθηκαν σε τρεις ίσες ομάδες (Ομάδα C: ESPB με N/S 0,9%, Ομάδα D: ESPB με ροπιβακαΐνη 0,375% και δεξμεδετομιδίνη 1mcg/kg και Ομάδα R: ESPB με ροπιβακαΐνη 0,375%). Ο αποκλεισμός πραγματοποιήθηκε αμφοτερόπλευρα, πριν την εισαγωγή στη γενική αναισθησία με υπερηχογραφική καθοδήγηση. Καταγράφηκαν η ποσότητα της διεγχειρητικά χορηγούμενης ρεμιφεντανίλης και της μετεγχειρητικής κατανάλωσης μορφίνης. Η ένταση του μετεγχειρητικού πόνου των ασθενών σε διαφορετικές χρονικές στιγμές καταγράφηκε με την κλίμακα NRS (Numerical Rating Scale). Καταγράφηκαν η μετεγχειρητική ναυτία και ο έμετος, ο χρόνος της πρώτης κινητοποίησης μετά την ολοκλήρωση της χειρουργικής επέμβασης, οι ημέρες νοσηλείας και η ικανοποίηση των ασθενών από τη μετεγχειρητική αναλγησία. Οι κανονικά κατανεμημένες, συνεχείς μεταβλητές εκφράστηκαν με τον αριθμητικό μέσο όρο ± μία σταθερή απόκλιση, ενώ οι συνεχείς μεταβλητές με μη κανονική κατανομή εκφράστηκαν με τη διάμεσο και το ενδοτεταρτημοριακό εύρος. Η στατιστική ανάλυση πραγματοποιήθηκε με τα τεστ ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis και Spearman test. Αποτελέσματα: Όλοι οι ασθενείς παρέμειναν αιμοδυναμικά σταθεροί διεγχειρητικά. Δεν παρατηρήθηκαν μείζονες επιπλοκές περιεγχειρητικά. Όλες οι ομάδες ήταν συγκρίσιμες μεταξύ τους. Η συνολική ποσότητα της ρεμιφεντανίλης που χορηγήθηκε διεγχειρητικά και η διάμεση συνολική κατανάλωση μορφίνης μετεγχειρητικά παρουσίασαν στατιστικά σημαντική διαφορά μεταξύ των τριών Ομάδων (p&lt;0,001 και p&lt;0,001 αντίστοιχα), αλλά η διάμεση συνολική κατανάλωση μορφίνης δε βρέθηκε να είναι στατιστικά διαφορετική μεταξύ των Ομάδων R και D (p=0,381). Το διάμεσο NRS σκορ των ασθενών βρέθηκε να είναι στατιστικά σημαντικά διαφορετικό μεταξύ των ομάδων σε όλες τις χρονικές στιγμές (p3=0,002, p6=0,017, p12=0,023, p24=0,01), μεταξύ των ομάδων C και D (p3&lt;0,001, p6=0,002, p12=0,002, p24&lt;0,01), αλλά όχι μεταξύ των ομάδων R και D (p3=0,175, p6=0,394, p12=0,08, p24=0,536). Η ικανοποίηση των ασθενών παρουσίασε στατιστικά σημαντική διαφορά μεταξύ των ομάδων C και D (p&lt;0,001) και επιπλέον στατιστικά σημαντική διαφορά βρέθηκε στο χρόνο πρώτης κινητοποίησης μεταξύ των ομάδων C και D (p=0,035) και μεταξύ των ομάδων C και R (p=0,015). Δε βρέθηκε στατιστικά σημαντική διαφορά μεταξύ των ομάδων σχετικά με την ύπαρξη μετεγχειρητικής ναυτίας και εμέτου και σχετικά με τις ημέρες νοσηλείας των ασθενών. Συμπεράσματα: Σε αυτή τη μελέτη, ο ESPB με τη χρήση ροπιβακαΐνης ή με τη χρήση ροπιβακαΐνης και συμπληρωματικά δεξμεδετομιδίνης, βρέθηκε να είναι πιο αποτελεσματικός στη διαχείριση του μετεγχειρητικού πόνου, στη μείωση των περιεγχειρητικά χορηγούμενων οπιοειδών, στην πρώιμη κινητοποίηση και στη μεγαλύτερη ικανοποίηση των ασθενών που υποβάλλονται σε προγραμματισμένη λαπαροσκοπική χολοκυστεκτομή, σε σχέση με την «αναλγησία ρουτίνας». Η πραγματοποίηση του ESPB στους ασθενείς που υποβάλλονται σε λαπαροσκοπική χολοκυστεκτομή είναι μια καινοτόμος, ασφαλής και απλή μέθοδος, η οποία μπορεί να βοηθήσει στη βελτίωση της ποιότητας της διεγχειρητικής αναλγησίας, στην αποφυγή των επιπλοκών από τη χορήγηση μεγάλων ποσοτήτων οπιοειδών και να συμβάλλει στην επίτευξη της πολυδύναμης αναλγησίας, ελεύθερης από οπιοειδή.Background: Laparoscopic cholecystectomy is one of the most common procedures performed by general surgeons. Although it is performed with minimally invasive techniques, postoperative pain can be moderate to severe, requiring administration of large doses of opioids perioperatively in combination with other categories of analgesics in order to be relieved. Bilateral Erector Spinae Plane block (ESPB) is a recently described trunk block, which is performed as a method of postoperative analgesia in various surgical procedures. The analgesic efficacy of ESPB in laparoscopic cholecystectomies has not been proven yet. In this study, we aimed to explore its efficacy as a perioperative analgesic method to patients undergoing elective laparoscopic cholecystectomy. Methods: This study was designed as a double-blinded, randomized, controlled, prospective study. A total of 60 patients were randomized into three equal groups (Group C: ESPB with N/S 0,9%, Group D: ESPB with ropivacaine 0,375% and dexmedetomidine 1 mcg/kg and Group R: ESPB with ropivacaine 0,375%). The ESPB was performed bilaterally before the induction of general anesthesia, with ultrasound guidance. The intraoperative remifentanil (mcg) and the postoperative morphine (mg) consumption were recorded. Pain intensity between groups at several time – points was compared using Numeric Rating Scale (NRS) scores. Post – operative nausea and vomiting, the time of first mobilization after completion of surgery, hospitalization days and satisfaction score of the patients were also recorded. Descriptive statistics were expressed as mean ± standard deviation or median, interquartile range. Statistical analysis was performed with ANOVA, two-way ANOVA for repeated measures, Kruskal-Wallis, Spearman test. Results: All patients remained hemodynamically stable throughout surgery. No major complications were observed perioperatively. All Groups were similar. The total intraoperative remifentanil and the median 24 h morphine consumption were statistically different between the three groups (p&lt;0,001 and p&lt;0,001 respectively), but regarding the median total morphine consumption, it was insignificant between Ropivacaine and Dexmedetomidine Groups (p=0,381). The median NRS scores of the patients at all time points were found to be statistically different between the three groups (p3=0,002, p6=0,017, p12=0,023, p24=0,01), between Groups C and D (p3&lt;0,001, p6=0,002, p12=0,002, p24&lt;0,01), but was not statistically significant between Groups R and D (p3=0,175, p6=0,394, p12=0,08, p24=0,536). Satisfaction score was found to be statistically significant between Group C and D (p&lt;0,001) and mobilization time was statistically significant between Groups C and D (p=0,035) and between Groups C and R (p=0,015). There was found no statistically significant difference regarding the post-operative nausea and vomiting and hospitalization days of the patients between the three groups. Conclusion: In this study, ESPB performed with ropivacaine and ESPB performed with ropivacaine and dexmedetomidine was found to be more effective in managing the perioperative pain, in reducing the intraoperative and postoperative consumption of opioids, in the early mobilization and in ameliorating the satisfaction score of the patients, compared to standard analgesia protocols in patients undergoing laparoscopic cholecystectomy. ESPB performance in patients scheduled for laparoscopic cholecystectomy is a novel, safe and simple method, which can help improve the quality of perioperative analgesia, avoid the complications of opioid administration to patients and thus achieve pre-emptive, multimodal and “opioid-free analgesia”