Administração peridural de morfina e fentanil em um felino: relato de caso

Um felino macho, sem raça definida, pesando 3,6 kg com 10 anos de idade foi atendido no Hospital Veterinário “Luiz Quintiliano de Oliveira”, apresentando obstrução uretral com indicação para uretrostomia perineal. Ao exame físico geral, observou-se freqüência cardíaca (FC) de 240 bat.min-1, taquipnéia, temperatura retal (TR) de 38,4oC, mucosas normocoradas, tempo de preenchimento capilar de um segundo e desidratação de aproximadamente 5%. Como medicação pré-anestésica, administrou-se cetamina (6mg.kg-1), midazolam (0,15mg.kg-1) e morfina (0,15mg.kg-1) pela via intramuscular. A veia cefálica foi canulada com cateter 24G para administração de Ringer com Lactato de sódio (10mL.kg-1.h-1) e a indução foi realizada por meio da administração de propofol (4,4mg.kg-1) pela via intravenosa. Seguiu-se a intubação orotraqueal com sonda no 4,0 conectando-se a um circuito sem reinalação de Baraka, sendo a manutenção anestésica efetuada com isofluorano em fluxo diluente de oxigênio a 100%. Em seguida, realizou-se a técnica de anestesia peridural com o paciente em posição esternal e membros pélvicos estendidos cranialmente. Após localização do espaço entre as vértebras L7 e S1, introduziu-se uma agulha 13x4,5 percutaneamente até atingir o espaço peridural, administrando-se morfina (0,1mg.kg-1), fentanil (3mcg.kg-1) e lidocaína a 1% com vasoconstritor (1,8mg.kg-1), perfazendo um volume total de 0,25mL.kg-1. Durante o procedimento anestésico, monitorou-se a FC, freqüência respiratória (f), pressão arterial sistólica (PAS), pressão parcial de dióxido de carbono ao final da expiração (ETCO2), temperatura esofágica (TE), saturação periférica da hemoglobina (SpO2) e plano anestésico. O tempo total de anestesia e cirurgia foi de 65 e 50 minutos, respectivamente. O plano anestésico manteve-se estável, sem a necessidade de resgate analgésico. A SpO2, concentração de isofluorano e TE mantiveram-se em 97±2%, 1,3±0,1% e 36,7±0,4oC, respectivamente. Durante a anestesia, observou-se um momento de hipotensão, provavelmente devido ao bloqueio simpático decorrente da anestesia peridural. Tal evento foi tratado com bolus de solução de Ringer com Lactato de sódio (5mL.kg-1) promovendo o retorno da PAS aos valores de normalidade. A recuperação anestésica do animal foi isenta de complicações inerentes ao procedimento anestésico. O emprego de opióides pela via peridural é recomendado em procedimentos cirúrgicos abdominal, torácico, genito-urinário e ortopédico, principalmente em pacientes de alto risco, obesos e idosos. Em humanos, a associação da morfina e fentanil pela via peridural demonstra analgesia pós-operatória superior à promovida pelo uso isolado da morfina. Conclui-se que na espécie felina, a associação de morfina e fentanil pela via peridural pode ser uma boa alternativa para realização de protocolos de anestesia balanceada para uretrostomia.

Lombalgia equina: diagnóstico e tratamento

Low back pain is considered a major cause of lameness and performance decay, but identify the location of the lesions and quantify the intensity of pain is difficult because often the most obvious clinical sign, in some cases, is not the pain itself, but, low athletic performance. The diagnosis and treatment of this disease are associated with a high cost and have a strong impact on the equine industry, since it results in direct economic losses. The diagnosis of low back pain is made through physical examination and additional tests, including radiography, ultrasound, thermography and blockades. Major injuries causing back pain in horses is the contact or overlap of the spinous processes, supraspinous desmitis, osteoarthritis of the articular processes, vertebral body lesions and myositis. Therapeutic measures used in the treatment of these diseases are systemic inflammatory steroid, local infiltration, acupuncture, chiropractic, physical therapy, changes in training and surgeries.

Acupuncture as therapeutic resource in patient with bruxism

Bruxism is the harmful habit of clenching or grinding the teeth during the day and / or night, with unconscious pattern, with particular intensity and frequency, outside the functional movements of chewing and swallowing. It is accepted that bruxism is a response controlled by the neurotransmitters dopamine system associated with emotional component. The proposed of treatment of bruxism with acupuncture aims to stimulate sensory fibers of the peripheral nervous system leading to electrical transmission by neurons sufficient to produce changes in the central nervous system. As a consequence there is the release of substances (cortisol, endorphins, dopamine, noradrenaline and serotonin) that promote wellness and restoration of harmony, be it psychological, biological and / or behavioral.

Sinais e sintomas na Síndrome de Costen associada a desordens temporomandibulares: relato de caso clínico

Costen’s syndrome is defined as a set of auditory signs and symptoms in patients with TMD. It is characterized by ear fullness, hearing loss, tinnitus, ear pain and vertigo with nystagmus.It has predilection for females and fourth decade of life. The multidisciplinary monitoring of these patients is imperative in its recognition and the establishment of effective therapy. In this paper we report a case of Costen’s Syndrome patient whose treatment consisted of advice on the etiology of the disorder and weekly sessions of acupuncture. The clinical features that led to the diagnosis and treatment plan, and the effectiveness of acupuncture as supportive therapy were also discussed.

Temporomandibular disorders in females: acupuncture compared to occlusal splint

To compare the effect of acupuncture and occlusal splint in the treatment of temporomandibular disorders (TMD) in female patients.Method: Forty-eight female patients (mean age of 39.3±6.8 years) with diagnosed pain in muscles or joint according to RDC/TMD criteria were attended at UNESP - Aracatuba Dental School. Including criteria were reported pain in the chewing muscles and/or in the temporomandibular joint measured by a visual analogue scale (range from 0 to 10) and a reported reduction of the maximum mouth opening. Excluding factors were major occlusal problems, systemic diseases, pregnancy and age below 18 years. After randomization, the first group was treated with acupuncture performed by instructed dentist. The second group was treated with occlusal splint. The outcome variables were assessed at baseline (prior to the first treatment session) and after 1, 3 and 6 months. Primary criteria of success were improvement of mouth opening and pain reduction.Result: Acupuncture group exhibited chewing pain decrease from 5 (at baseline) to 1, 2 and 1 after 1, 3 and 6 months, respectively. In the splint group, chewing pain decreased from 4 to 2, 1 and 2 after 1, 3 and 6 months, respectively. The mouth opening (in mm) increased from 28 (at baseline) to 42, 44 and 46 after 1, 3 and 6 months, respectively in the acupuncture group. In the splint group, mouth opening improved from 29 to 40 after 1 month, and to 43 and 42 after 3 and 6 months. A significant pain reduction was noted for both groups when compared to the baseline (p<.001; Wilcoxon test). Acupuncture group had a significant clinical improvement of opening mouth (Mann-Whitney). Conclusion: The present outcomes suggest a positive association among acupuncture and occlusal splint on the reduction of chewing pain. Acupuncture was more effective in the mouth opening increase.

Efeito de um tratamento com auriculoterapia na dor, funcionalidade e mobilidade de adultos com dor lombar crônica

Pós-graduação em Desenvolvimento Humano e Tecnologias - IBRC

Duloxetina para melhoria na qualidade de recuperação anestésica em histerectomia abdominal

Pós-graduação em Anestesiologia - FMB

Fechamento de defeitos em padrão de figura geométrica associado ao emprego de anestesia por tumescência com lidocaína em coelhos (oryctolagus cuniculus)

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Utilização do sufentanil durante indução anestésica em anestesia venosa total com remifentanil em infusão contínua

Pós-graduação em Anestesiologia - FMB

Activation of 5-HT2C receptors in the dorsal periaqueductal gray increases antinociception in mice exposed to the elevated plus-maze

Several findings have pointed to the role of the dorsal periaqueductal gray (dPAG) serotonin 5-HT1A and 5-HT2(A-C) receptor subtypes in the modulation of defensive behavior in animals exposed to the elevated plus-maze (EPM). Besides displaying anxiety-like behavior, rodents also exhibit antinociception in the EPM. This study investigated the effects of intra-dPAG injections of 5-HT1A and 5-HT2B/2C receptor ligands on EPM-induced antinociception in mice. Male Swiss mice received 0.1 mu l intra-dPAG injections of vehicle, 5.6 and 10 nmol of 8-OHDPAT, a 5-HT1A receptor agonist (Experiment 1), or 0.01, 0.03 and 0.1 nmol of mCPP, a 5-HT2B/2C receptor agonist (Experiment 2). Five minutes later, each mouse received an intraperitoneal injection of 0.6% acetic acid (0.1 ml/10 g body weight; nociceptive stimulus) and was individually confined in the open (OA) or enclosed (EA) arms of the EPM for 5 min, during which the number of abdominal writhes induced by the acetic acid was recorded. While intra-dPAG injection of 8-OHDPAT did not change open-arm antinociception (OAR). mCPP (0.01 nmol) enhanced it. Combined injections of ketanserin (10 nmol/0.1 mu l), a 5-HT2A/2C receptor antagonist, and 0.01 nmol of mCPP (Experiment 3), selectively and completely blocked the OAR enhancement induced by mCPP. Although intra-dPAG injection of mCPP (0.01 nmol) also produced antinociception in EA-confined mice (Experiment 2), this effect was not confirmed in Experiment 3. Moreover, no other compound changed the nociceptive response in EA-confined animals. These results suggest that the 5-HT2C receptors located within the PAG play a role in this type of environmentally induced pain inhibition in mice. (c) 2012 Elsevier B.V. All rights reserved.

Into the Island: A new technique of non-invasive cortical stimulation of the insula

Study aim. - We describe a new neuronavigation-guided technique to target the posterior-superior insula (PSI) using a cooled-double-cone coil for deep cortical stimulation. Introduction. - Despite the analgesic effects brought about by repetitive transcranial magnetic stimulation (TMS) to the primary motor and prefrontal cortices, a significant proportion of patients remain symptomatic. This encouraged the search for new targets that may provide stronger pain relief. There is growing evidence that the posterior insula is implicated in the integration of painful stimuli in different pain syndromes and in homeostatic thermal integration. Methods. - The primary motor cortex representation of the lower leg was used to calculate the motor threshold and thus, estimate the intensity of PSI stimulation. Results. - Seven healthy volunteers were stimulated at 10 Hz to the right PSI and showed subjective changes in cold perception. The technique was safe and well tolerated. Conclusions. - The right posterior-superior insula is worth being considered in future studies as a possible target for rTMS stimulation in chronic pain patients. (c) 2012 Elsevier Masson SAS. All rights reserved.

Replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial

Introduction: Patients undergoing mechanical ventilation (MV) are frequently administered prolonged and/or high doses of opioids which when removed can cause a withdrawal syndrome and difficulty in weaning from MV. We tested the hypothesis that the introduction of enteral methadone during weaning from sedation and analgesia in critically ill adult patients on MV would decrease the weaning time from MV. Methods: A double-blind randomized controlled trial was conducted in the adult intensive care units (ICUs) of four general hospitals in Brazil. The 75 patients, who met the criteria for weaning from MV and had been using fentanyl for more than five consecutive days, were randomized to the methadone (MG) or control group (CG). Within the first 24 hours after study enrollment, both groups received 80% of the original dose of fentanyl, the MG received enteral methadone and the CG received an enteral placebo. After the first 24 hours, the MG received an intravenous (IV) saline solution (placebo), while the CG received IV fentanyl. For both groups, the IV solution was reduced by 20% every 24 hours. The groups were compared by evaluating the MV weaning time and the duration of MV, as well as the ICU stay and the hospital stay. Results: Of the 75 patients randomized, seven were excluded and 68 were analyzed: 37 from the MG and 31 from the CG. There was a higher probability of early extubation in the MG, but the difference was not significant (hazard ratio: 1.52 (95% confidence interval (CI) 0.87 to 2.64; P = 0.11). The probability of successful weaning by the fifth day was significantly higher in the MG (hazard ratio: 2.64 (95% CI: 1.22 to 5.69; P < 0.02). Among the 54 patients who were successfully weaned (29 from the MG and 25 from the CG), the MV weaning time was significantly lower in the MG (hazard ratio: 2.06; 95% CI 1.17 to 3.63; P < 0.004). Conclusions: The introduction of enteral methadone during weaning from sedation and analgesia in mechanically ventilated patients resulted in a decrease in the weaning time from MV.

Antinociception induced by acute oral administration of sweet substance in young and adult rodents: The role of endogenous opioid peptides chemical mediators and mu(1)-opioid receptors

The present work aimed to investigate the effects of acute sucrose treatment on the perception of painful stimuli. Specifically, we sought to determine the involvement of the endogenous opioid peptide-mediated system as well as the role of the mu(1)-opioid receptor in antinociception organisation induced by acute sucrose intake. Nociception was assessed with the tail-flick test in rats (75, 150 and 250 g) of different ages acutely pre-treated with 500 mu L. of a sucrose solution (25, 50, 150 and 250 g/L) or tap water. Young and Adult rats (250 g) showed antinociception after treatment with 50 g/L (during 5 min) and 150 g/L and 250 g/L (during 20 min) sucrose solutions. Surprisingly, this antinociception was more consistent in mature adult rodents than in pups. To evaluate the role of opioid systems, mature adult rodents were pre-treated with different doses (0.25, 1 or 4mg/kg) of the non-selective opioid receptor antagonist naloxone, the selective pi-opioid receptor antagonist naloxonazine or vehicle followed by 250 g/L sucrose solution treatment. Sucrose-induced antinociception was reduced by pre-treatment with both naloxone and naloxonazine. The present findings suggest that sweet substance-induced hypo-analgesia is augmented by increasing sucrose concentrations in young and adult rodents. Acute oral sucrose treatment inhibits pain in laboratory animal by mediating endogenous opioid peptide and mu(1)-opioid receptor actions. (C) 2011 Elsevier Inc. All rights reserved.

Endogenous opioid peptide-mediated neurotransmission in central and pericentral nuclei of the inferior colliculus recruits mu(1)-opioid receptor to modulate post-ictal antinociception

Background: The aim of the present work was to investigate the involvement of the mu(1)-endogenous opioid peptide receptor-mediated system in post-ictal antinociception. Methods: Antinociceptive responses were determined by the tail-flick test after pre-treatment with the selective mu(1)-opioid receptor antagonist naloxonazine, peripherally or centrally administered at different doses. Results: Peripheral subchronic (24 h) pre-treatment with naloxonazine antagonised the antinociception elicited by tonic-clonic seizures. Acute (10 min) pre-treatment, however, did not have the same effect. In addition, microinjections of naloxonazine into the central, dorsal cortical and external cortical nuclei of the inferior colliculus antagonised tonic-clonic seizure-induced antinociception. Neither acute (10-min) peripheral pre-treatment with naloxonazine nor subchronic intramesencephalic blockade of mu(1)-opioid receptors resulted in consistent statistically significant differences in the severity of tonic-clonic seizures shown by Racine's index (1972), although the intracollicular specific antagonism of mu(1)-opioid receptor decreased the duration of seizures. Conclusion: mu(1)-Opioid receptors and the inferior colliculus have been implicated in several endogenous opioid peptide-mediated responses such as antinociception and convulsion. The present findings suggest the involvement of mu(1)-opiate receptors of central and pericentral nuclei of the inferior colliculus in the modulation of tonic-clonic seizures and in the organisation of post-ictal antinociception. (C) 2011 Elsevier Ltd. All rights reserved.

Analgesic effects of repetitive transcranial magnetic stimulation of the motor cortex in neuropathic pain: Influence of theta burst stimulation priming

Background Conventional protocols of high-frequency repetitive transcranial magnetic stimulation (rTMS) delivered to M1 can produce analgesia. Theta burst stimulation (TBS), a novel rTMS paradigm, is thought to produce greater changes in M1 excitability than conventional protocols. After a preliminary experiment showing no analgesic effect of continuous or intermittent TBS trains (cTBS or iTBS) delivered to M1 as single procedures, we used TBS to prime a subsequent session of conventional 10?Hz-rTMS. Methods In 14 patients with chronic refractory neuropathic pain, navigated rTMS was targeted over M1 hand region, contralateral to painful side. Analgesic effects were daily assessed on a visual analogue scale for the week after each 10?Hz-rTMS session, preceded or not by TBS priming. In an additional experiment, the effects on cortical excitability parameters provided by single- and paired-pulse TMS paradigms were studied. Results Pain level was reduced after any type of rTMS procedure compared to baseline, but iTBS priming produced greater analgesia than the other protocols. Regarding motor cortex excitability changes, the analgesic effects were associated with an increase in intracortical inhibition, whatever the type of stimulation, primed or non-primed. Conclusions The present results show that the analgesic effects of conventional 10?Hz-rTMS delivered to M1 can be enhanced by TBS priming, at least using iTBS. Interestingly, the application of cTBS and iTBS did not produce opposite modulations, unlike previously reported in other systems. It remains to be determined whether the interest of TBS priming is to generate a simple additive effect or a more specific process of cortical plasticity.