Fast Track (Acerto) in Elderly Patients for Hip Orthopedic Surgeries. Ten Years of Experience

In 2010, we started implementing the ACERTO project in a hospital in the northeast of the Brazilian Public Health (SUS) after five weeks with all stakeholders involved in the departments of Anesthesiology, Orthopedics, Geriatrics, Nutrition, Nursing, Physiotherapy, Psychology and Social Service. In the same way as in other hospitals, the implementation of fast track surgery was not obtained by all departments and all health professionals. The use of ACERTO protocol with clinical measures of accelerating patient recovery decreased length of stay, the number of suspensions of surgery, the need for ICU, the use of vesical catheter, the time of fasting, the time of oral food reintroduction, high earlier and faster return to family life, working as humanization of treatment to the elderly. Analgesia in all patients was obtained with local anesthetics through different plexus blocks with neurostimulator and no patient used spinal opioids. In medicine the vast majority is terribly attached to their arguments and no one is willing to give in to new truths. Dreaming costs nothing and the implementation of the ACERTO Project will cost nothing to any institution

Cross-talk between Human Spinal Cord μ-opioid Receptor 1Y Isoform and Gastrin-releasing Peptide Receptor Mediates Opioid-induced Scratching Behavior

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Although spinal opioids are safe and effective, pruritus is common and distressing. The authors previously demonstrated in mouse spinal cord that interactions between μ-opioid receptor isoform 1D and gastrin releasing peptide receptor mediate morphine-induced scratch. The C-terminal of 1D inhibits morphine-induced scratch without affecting analgesia. The authors hypothesize that human spinal cord also contains itch-specific μ-opioid receptor isoforms which interact with gastrin releasing peptide receptor. Methods Reverse transcription polymerase chain reaction was performed on human spinal cord complimentary DNA from two human cadavers. Calcium responses to morphine (1 μM) were examined using calcium imaging microscopy on human cells (HEK293) coexpressing gastrin releasing peptide receptor and different human μ-opioid receptor isoforms. The authors assessed morphine-induced scratching behavior and thermal analgesia in mice following intrathecal injection of morphine (0.3 nmol) and a transactivator of transcription peptide designed from C-terminal sequences of 1Y isoform (0, 0.1, and 0.4 nmol). Results The authors demonstrated 1Y expression in the spinal cord dorsal horn. Morphine administration evoked a calcium response (mean ± SD) (57 ± 13 nM) in cells coexpressing both gastrin releasing peptide receptor and the 1Y isomer. This was blocked by 10 μM naltrexone (0.7 ± 0.4 nM; P < 0.0001), 1 μM gastrin-releasing peptide receptor antagonist (3 ± 2 nM; P < 0.0001), or 200 μM 1Y-peptide (2 + 2 nM; P < 0.0001). In mice, 0.4 nmol 1Y-peptide significantly attenuated morphine-induced scratching behaviors (scratching bouts, vehicle vs. 1Y-peptide) (92 ± 31 vs. 38 ± 29; P = 0.011; n = 6 to 7 mice per group), without affecting morphine antinociception in warm water tail immersion test (% of maximum possible effect) (70 ± 21 vs. 67 ± 22; P = 0.80; n = 6 mice per group). Conclusions Human μ-opioid receptor 1Y isomer is a C-terminal splicing variant of Oprm1 gene identified in human spinal cord. Cross-talk between 1Y and gastrin releasing peptide receptor is required for mediating opioid-induced pruritus. Disrupting the cross talk may have implications for therapeutic uncoupling of desired analgesic effects from side effects of opioids.

Anesthetic effects of varying doses of Fentanyl combined with spinal Bupivacaine in caesarean delivery

<p><strong>Introduction</strong></p><p>Spinal opioids have gained popularity in recent years as they augment the analgesia produced by local anesthetics. Fentanyl is one of the opioids used for such purpose however the optimal dose has not been described adequately in the literature available so far in our setup. The aim of this study is to find out the effect of adding various doses of Fentanyl to low dose hyperbaric Bupivacaine intrathecally.</p><p><strong>Materials and methods</strong></p><p>Seventy-five parturients scheduled for caesarean delivery were randomly allocated into three groups (Bupivacaine-Fentanyl) BF10, BF20 and BF30 who received intrathecal 0.5% hyperbaric Bupivacaine 1.6 ml with Fentanyl 10µg, 20 µg and 30 µg respectively. Total volume was made to 2.2ml by adding normal saline. The outcomes measured were peak sensory level, degree of motor block, quality of intraoperative anesthesia, duration of effective analgesia, neonatal APGAR score and side effects were noted if any.</p><p><strong>Results</strong></p><p>Peak sensory level and degree of motor block was similar in all the groups. Peak sensory level (Thoracic Dermatome) was 4.52± 0.82, 4.32± 0.62 and 4.32± 0.74 (p=0.540) in BF10, BF20 and BF30 respectively. Degree of motor block was not significantly different (p=1.000). Quality of intraoperative anesthesia improved from BF10 to BF20 (P=0.040) but did not improve significantly from BF20 and BF30 (P=0.189). Duration of effective analgesia prolonged as the dose of Fentanyl increased which was in minutes 173.64±41, 216.80±32 and 273.16±35 (p=0.000) in BF10,BF20 and BF30 respectively. Neonatal APGAR scores were similar in all groups and very little adverse effects in higher doses.</p><p> <strong>Conclusion</strong></p><p>The combination of 1.6 ml of 0.5% hyperbaric Bupivacaine and 20 µg of Fentanyl intrathecally provides excellent surgical anesthesia, prolonged postoperative effective analgesia with very few side effects. Increasing the dose of Fentanyl beyond it could prolong the postoperative pain relief but at the cost of increased adverse effects.</p>

Anesthetic effects of varying doses of Fentanyl combined with spinal Bupivacaine in caesarean delivery

Introduction: Spinal opioids have gained popularity in recent years as they augment the analgesia produced by local anesthetics. Fentanyl is one of the opioids used for such purpose however the optimal dose has not been described adequately in the literature available so far in our setup. The aim of this study is to find out the effect of adding various doses of Fentanyl to low dose hyperbaric Bupivacaine intrathecally.Materials and methods:Seventy-five parturients scheduled for caesarean delivery were randomly allocated into three groups (Bupivacaine-Fentanyl) BF10, BF20 and BF30 who received intrathecal 0.5% hyperbaric Bupivacaine 1.6 ml with Fentanyl 10µg, 20 µg and 30 µg respectively. Total volume was made to 2.2ml by adding normal saline. The outcomes measured were peak sensory level, degree of motor block, quality of intraoperative anesthesia, duration of effective analgesia, neonatal APGAR score and side effects were noted if any.Results: Peak sensory level and degree of motor block was similar in all the groups. Peak sensory level (Thoracic Dermatome) was 4.52± 0.82, 4.32± 0.62 and 4.32± 0.74 (p=0.540) in BF10, BF20 and BF30 respectively. Degree of motor block was not significantly different (p=1.000). Quality of intraoperative anesthesia improved from BF10 to BF20 (P=0.040) but did not improve significantly from BF20 and BF30 (P=0.189). Duration of effective analgesia prolonged as the dose of Fentanyl increased which was in minutes 173.64±41, 216.80±32 and 273.16±35 (p=0.000) in BF10,BF20 and BF30 respectively. Neonatal APGAR scores were similar in all groups and very little adverse effects in higher doses.Conclusion: The combination of 1.6 ml of 0.5% hyperbaric Bupivacaine and 20 µg of Fentanyl intrathecally provides excellent surgical anesthesia, prolonged postoperative effective analgesia with very few side effects. Increasing the dose of Fentanyl beyond it could prolong the postoperative pain relief but at the cost of increased adverse effects.

Why do Pain Physicians Not Routinely Use Mixed Opioids for the Prevention of Neuraxial Opioid-induced Pruritus?

Background: Pruritus is a very disturbing secondary effect that appears after epidural or intrathecal administration of opioid drugs, especially in the management of postoperative pain. It is induced by the activation of mu opioid receptors and it can often be even more unpleasant than the pain being treated. Objective: A wide variety of drugs with different mechanisms of action have been used, aiming at the prevention of pruritus, with varying results. The aim of this comprehensive review letter is to summarize the current evidence of the available pharmacological options to either treat or prevent pruritus induced by spinal opioids. Method: The articles used in the review were found through a search in Medline, PubMed and Cochrane Library up to December 2016, using the keywords “Neuraxial opioids”, “Intrathecal morphine”, “Pruritus”, “Naloxone”, “Nalbuphine” and “Butorphanol”. Results: The most useful drugs act on the mu and kappa opioid receptors. They are either mu opioid antagonists, like intravenous naloxone, or mixed opioids mu antagonists/kappa agonists, such as intravenous nalbuphine and intravenous or epidural butorphanol, the latter being able also for maintaining the analgesia. Conclusion: Both pruritus prevention and treatment remain a challenge in the treatment of patients receiving spinal opioids for postoperative pain. Recent findings suggest that mixed opioids must be added to evidence-based clinical guidelines for the management of pruritus induced by spinal opioids.