<p>Hirur&scaron;ka inetrvencija aktivira odgovor organizma na stres, pokreću se neuroendokrine promene u organizmu, &scaron;to rezultira neželjenom hemodinamskom nestabilno&scaron;ću, promenama metabolizma, endokrinog i imunog sistema. Cilj ovog istraživanja je bio da se utvrdi uticaj kaudalnog bloka na nivo perioperativnog stresa i njegova efikasnot u zbrinjavanju intra- i postoperativnog bola. Ovo prospektivno, randomizirano kliničko ispitivanje obuhvatalo je 80 dečaka, uzrasta 2-5godina, kojima su bile indikovane urolo&scaron;ke operacije. Jedna grupa (n = 38) je primila op&scaron;tu anesteziju, a druga (n = 38) op&scaron;tu anesteziju sa kaudalnim blokom. Mereni su intraoperativno hemodinamski parametri u 8 merenja, ukupna potro&scaron;nja svih datih lekova i intenzitet bola u 3 navrata postoperativno. Uzorci krvi uzeti su pre uvoda u anesteziju i nakon buđenja pacijenta, i ispitivan je nivo glukoze, kortizola, leukocita, leukocitarne formule, pH i laktata. Deca koja su primila kaudalni blok imala su, postoperativno, značajno niži nivo glukoze u serumu (p &lt;0,01), koncentracije kortizola (p &lt;0,01), leukocita i neutrofila (p &lt;0,01), laktata i acidoze, a takođe su imali i niže ocene bola u sve tri momenta merenja (p&lt;0,01). Intraoperativno utvrđena je veća hemodinamska stabilnost i manja potro&scaron;nja analgetika perioperativno. Takođe, u toj grupi nije bilo komplikacija. Kombinacija kaudalnog bloka sa op&scaron;tom anestezijom je bezbedna metoda, koja dovodi do manjeg stresa, veće hemodinamske stabilnosti, nižih ocena bola i manje potro&scaron;nje<br />lekova.</p> / <p>Surgery generates a neuroendocrine stress response, resulting in undesirable haemodynamic instability, alterations in metabolic response and malfunctioning of the immune system. The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods. This prospective, randomized clinical trial included 80 patients scheduled for elective urological operations. One group (n = 38) received general anaesthesia and the other (n = 38) received general anaesthesia with a caudal block. Haemodynamic paramethers, drug consumption and pain intensity were measured. Blood samples for serum glucose, cortisol level, leukocytes, pH and lactate level were taken before anaesthesia induction and after awakening the patient. Children who received a caudal block had, postoperativly, significantly lower serum glucose (p &lt; 0.01), cortisol concentrations (p &lt; 0.01), leukocytes (p&lt;0,01), lower lactate level and acidosis,also pain scores were lower at all 3 measurments (p&lt;0,01). Intraoperativly greater haemodynamic stability and lower drug consumption were noticed. Also, there were no side effects or complications identified in that group. The combination of caudal block with general anaesthesia is a safe method that leads to less stress, greater haemodynamic stability, lower pain scores and lower consumption of medication.</p>

<p>U savremenoj hirurgiji imperativ je da hirur&scaron;ka procedura bude efikasna, ali i da obezbedi kvalitetan i brz oporavak. Najbitniji segment operativnog lečenja je obezbediti maksimalan učinak kako bi se osobi omogućio brz i potpun povratak aktivnostima dnevnog života. Posebno je pojačano&nbsp;&nbsp; interesovanje za rekonstrukciju prednjeg ukr&scaron;tenog ligamenta kod mlađe i sporsko aktivne populacije. Trendovi u medicini kao i u ortopedskoj hirurgiji idu u pravcu smanjenja postoperativnog krvarenja, bola i skraćenja postoperativnog oporavka. Supstancija sa antifibrinolitičkim delovanjem, kao &scaron;to je traneksamična kiselina, svakako je na&scaron;la svoje mesto u smanjenju postoperativnog krvarenja. Ciljevi istraživanja su se odnosili na utvrđivanje uticaja lokalno aplikovane traneksamične kiseline tokom rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena na postoperativno krvarenje, posmatrane laboratorijske parametre, mere obima kolena, učestalosti postoperativnih komplikacija i kvaliteta postoperativnog oporavka između dve grupe ispitanika (ispitivana i kontrolna grupa). Studija je bila eksprimentalnog karaktera i sprovedena je u Kliničkom centru Vojvodine u Novom Sadu uz odobrenje etičke komisije. U istraživanje, metodom slučajnog izbora, bila su uključena 124 ispitanika oba pola raspoređena u dve grupe (ispitivana i kontrolna), a kod kojih je indikovana operativno zbrinjavanje prekida prednjeg ukr&scaron;tenog ligamenta kolena i koji su dali pristanak da budu uključeni u studiju. Svi prikupljeni podaci su beleženi u protokol, koji je za ovo istraživanje posebno dizajniran. Ispitanici su bili podvrgnuti operativnom zahvatu, uz primenu op&scaron;te ili spinalne anestezije, sa postavljenom pneumatskom poveskom na operisanom ekstremitetu. Ispitivanoj grupi bilo je lokalno aplikovano 20 ml traneksamične kiseline, dok je u kontolnoj grupi na isti način aplikovano 20 ml NaCl 0,9 % rastvora. Postoperativni gubici krvi su praćeni i beleženi tokom 24 h od operacije, dok su laboratorijki nalazi uzorkovani preoperativno i sedmog postoperativnog dana. U posmatranom periodu (preoperativno, sedmog postoperativnog dana, treće i &scaron;este postoperativne nedelje) kod ispitanika je praćen obim kolena i pojava komplikacija (hematom, hemartroza). Nakon sprovedenog istraživanje, prikupljeni podaci su dokumentovani i statistički obrađeni. Rezultati istraživanja jasno ukazuju da postoji statistički značajna razlika (t=7.181, p&lt;0.001) u količni postoperativnog krvarenja između grupa. Prosečno postoperativno krvarenje u ispitivanoj grupi je bilo 71.29&plusmn;40.76 ml, u odnosu na kontrolnu grupu gde je postoperativno krvarenje iznosilo 154.35&plusmn;81.45 ml. U kontrolnoj grupi, postoperativno se beleže niže vrednosti hemoglobina (t=9.608, p&lt;0.001) i hematokrita (t=8.325, p&lt;0.001), i vi&scaron;e vrednosti trombocita (t=2.201, p=0.032) nego u ispitivanoj grupi. Podaci o postoperativnom bolu ispitanika govore u prilog statistički značajnoj razlici u jačini bola prve nedelje nakon operacije između ispitivane i kontrolne grupe (t=2.405, p=0.018) i treće nedelje nakon operacije (t=3.700, p&lt;0.001). U ispitivanoj grupi zabeležena je ređa pojava hematoma 6.45% (n=4), dok je u kontrolnoj grupi 19.35% (n=12). Svi pacijenti u uzorku su popunili upitnik o postoperativnom kvalitetu oporavka. Nije zabeležena statistički značajna razlika u kvalitetu postoperativnog oporavka nakon operacije između dve analizirane grupe ispitanika. Dobijeni rezultati o postoperativnom krvarenju, nakon aplikovane traneksamične kiseline, ukazuju na efikasnost leka i pri lokalnoj primeni tokom rekonstrukcije prednjeg ukr&scaron;tenog ligamenta kolena. S obzirom na insuficijentnost podataka, ovo ispitivanje stvara &scaron;iru osnovu za dalja istraživanja.</p> / <p>In modern surgery, we need an effective surgical procedure, which provides quality and rapid recovery. The most important segment of surgical treatment is to provide maximum impact to allow a person to return quickly and fully to the activities of daily living. There has been particular interest in the reconstruction of the anterior cruciate ligament in the younger and sport active population. Trends in medicine, as well as in orthopedic surgery, are heading towards reducing postoperative bleeding, pain, and postoperative recovery. A substance with antifibrinolytic activity, such as tranexamic acid, has certainly found its place in reducing postoperative bleeding. The objectives of the study were to determine the effect of locally applied tranexamic acid during the reconstruction of the anterior cruciate knee ligament on postoperative bleeding, observed laboratory parameters, measures of knee circumference, frequency of postoperative complications, and quality of postoperative recovery between the two groups of subjects (study and control group). The study was prospective, conducted at the Clinical Center of Vojvodina in Novi Sad with the approval of the ethics committee. The study, by random selection method, included 124 subjects of both sexes, divided into two groups (tested and control), which indicated operative management of the anterior cruciate ligament rupture and gave informed consent for inclusion in the study. All data collected were recorded in a protocol, which was specifically designed for this research. Subjects underwent surgery, with general or spinal anesthesia, with pneumatic attachment placed on the extremity undergoing surgery. The test group was given topically 20 ml of tranexamic acid, while the control group was administered 20 ml in the same way. NaCl 0.9% solution. Postoperative blood losses were monitored and recorded within 24 h of surgery, while laboratory findings were sampled preoperatively and on the seventh postoperative day. During the observed period (preoperatively, on the seventh postoperative day, on the third and sixth postoperative weeks), the knee volume and the occurrence of complications (hematoma, hemarthrosis) were monitored in the subjects. Following the survey, the data collected were documented and statistically processed. The study results indicate that there was a statistically significant difference (t = 7.181, p &lt;0.001) in the amount of postoperative bleeding between groups. The mean postoperative bleeding in the study group was 71.29 &plusmn; 40.76 ml, compared to the control group where postoperative bleeding was 154.35 &plusmn; 81.45ml. In the control group, lower hemoglobin values (t = 9.608, p &lt;0.001) and hematocrit (t = 8.325, p &lt;0.001) were observed postoperatively, and higher platelet counts (t = 2.201, p = 0.032) than in the study group. The data on the postoperative pain of the respondents support a statistically significant difference in the severity of pain on the first week after surgery between the study and the control group (t = 2.405, p = 0.018) and the third week after surgery (t = 3.700, p &lt;0.001). In the study group, the incidence of hematoma was less than 6.45% (n = 4), while in the control group it was 19.35% (n = 12). All patients in the sample completed a questionnaire on postoperative quality of recovery. There was no statistically significant difference in the quality of postoperative recovery after surgery between the two analyzed groups of subjects. The results of post-operative bleeding, after administrated tranexamic acid, indicate the efficacy of the drug and at a local application during the reconstruction of the anterior cruciate ligament. Due to the insufficiency of data, this study creates a broad basis for further research.</p>

Made available in DSpace on 2014-07-29T15:04:30Z (GMT). No. of bitstreams: 1 Luciano Ramos de Lima.pdf: 1365345 bytes, checksum: ef60ed7553c3b76d00042fe7e22ffcb3 (MD5) Previous issue date: 2009-06-16 / Postoperative pain is characterized as an acute pain, prevalent inside the hospital environment, commonly associated with tissue damage. This study had, as a general objective, the evaluation of post-operative pain in clients who have undergone to cardiac surgery by sternotomy, according to the occurrence, intensity (measured at rest and on deep inspiration), location and quality, 1st, 2nd and 3rd. This is a cohort, prospective study, developed in a general hospital in the countryside of the State of Goiás, in the period from January to August 2008. Pain intensity was measured by means of verbal numerical scale (0-10); quality was measured by the McGill Pain Questionnaire (MPQ-SF), the location was measured by body diagrams, and preoperative anxiety was measured via STAI (State/Trait Anxiety Inventory). Numerical vares were explored by descriptive measures of centrality (mean and median) and dispersion (minimum, maximum, standard deviation). The categorical variables were explored by simple absolute frequencies and percentages. The associations between variables were explored using non-parametric association tests, such as chi-square, Spearman coefficient, Kruskal-Wallis and Mann-Whitney with &#945; = 5%. 62 clients participated, 56.5% men, 67.7% white, 42% of socioeconomic class C and 72.6% married. The mean age was 54.8 years, SD = 12.1 years, and the predominant age group (29.0%) from 51 to 60 years. The prevalent surgery was valve surgery (46.8%), followed by myocardial revascularization (40.3%). The postoperative anxiety level was medium to 92.0% of the clients. Pain intensity at rest and deep inspiration had a decrease as days passed by, (p<0.05), being classified as mild-moderate (MD [median]=0,0-3,0; Q1 [quartile 1]=0,0-1,0; Q3 [quartile 3]=2,0-6,0; MAX [maximum]=8,0-10,0; MIN [minimum]=0,0-0,0) at rest and moderate-intense (MD=2,0-5,0; Q1=0,75-2,75; Q3=3,0-7,25; MAX=9,0-10,0; MIN=0,0-0,0) at deep inspiration. The chest region was the region in where there was the greatest pain occurrence in the 4 days of PO (40,3%-53,2%).The words which were most frequently chosen to describe postoperative pain were tiring/exhaustive (83,9%- 95,2%), painful (88,7%-91,9%), persistent (85,5%-87,1%) and splitting (72,6%- 82,3%). Splitting, was the one which received the greatest attribution (score 3) from the sensory-discriminative group, in numerical scale (0-3), both at POI as in the 1st and 2nd PO. The PRI (Pain Rating Index), results from the MPQ-SF, for the sensory group (PRI-S) , the affective group (PRI-A) and total (PRI-T) showed a reduction in the scores over the 4 days of PO (p<0.001). The correlation between the pain intensity and PRI scores in the 4 days of PO was positive and significant both for the PRI-S (0.52-0.34; p<0.001), and PRI-A (0.52-0.30; p<0.001) as to PRI-T (0.56-0.36; p<0.001). Postoperative pain at rest intensity was consistent to the one observed in other studies. However, postoperative pain at deep inspiration is still intense, being able to generate greatest losses in the clients early recovery. Even tough it isn t significantly associated to pain intensity, it is stressed that all the clients presented some degree of anxiety, a natural stimulus which can influence the endogenous pain modulation system, which may exacerbate the pain. In terms of quality, pain was described through words from the sensory and affective MPQ group, pointing to the multidimensionality of the painful experience. It is stressed the importance of the evaluation/measure and the postoperative pain systematic record as essential items to the adequate relief of this experience in the surgical environment. / A dor pós-operatória caracteriza-se como dor aguda, prevalente no âmbito hospitalar, comumente associada a um dano tecidual. Este estudo teve como objetivo geral avaliar a dor pós-operatória, em clientes submetidos a cirurgias cardíacas, por esternotomia, segundo a ocorrência, intensidade (mensurada ao repouso e à inspiração profunda), localização e qualidade, no POI, 1º, 2º e 3º PO. Trata-se de uma coorte, prospectiva, desenvolvida em um hospital geral do interior do Estado de Goiás, no período de janeiro a agosto 2008. A intensidade da dor foi medida por meio da Escala Numérica (0-10) verbal; a qualidade pelo Questionário de Dor de McGill (MPQ-SF); a localização por meio de diagramas corporais; e a ansiedade pré-operatória por meio do IDATE-estado. As variáveis numéricas foram exploradas pelas medidas descritivas de centralidade (média e mediana) e de dispersão (mínimo, máximo, desvio padrão) e as variáveis categóricas por freqüências simples absolutas e porcentuais. As associações entre as variáveis foram exploradas por meio de testes não paramétricos de associações como o quiquadrado, coeficiente de Spearman, Kruskal-Wallis e Mann-Whitney, com &#945;=5%. Participaram 62 pacientes, 56,5% do sexo masculino, 67,7% brancos, 42% da classe socioeconômica C e 72,6% casados. A média de idade foi de 54,8 anos; d.p.=12,1 anos, e a faixa etária predominante (29,0%) de 51 a 60 anos. A cirurgia prevalente foi a valvar (46,8%) seguida pela revascularização do miocárdio (40,3%). O nível de ansiedade pré-operatória foi médio para 92,0% dos clientes. A intensidade de dor ao repouso e à inspiração profunda declinou com o passar dos dias (p<0,05), sendo classificada como leve-moderada (MD=0,0-3,0; Q1=0,0-1,0; Q3=2,0-6,0; MAX=8,0-10,0; MIN=0,0-0,0) ao repouso e moderada-intensa, (MD=2,0- 5,0; Q1=0,75-2,75; Q3=3,0-7,25; MAX=9,0-10,0; MIN=0,0-0,0) à inspiração profunda. Os locais de maior ocorrência de dor, nos 4 dias PO, foi a região peitoral (40,3% a 53,2%). As palavras escolhidas com maior freqüência para descrever a dor pós-operatória foram cansativa/exaustiva (83,9% a 95,2%), doída (88,7% a 91,9%), enjoada (85,5% a 87,1%) e rachando (72,6% a 82,3%) sendo que rachando, do agrupamento sensitivo-discriminativo foi a que recebeu maior atribuição (escore 3), em escala numérica (0-3), tanto no POI como no 1º e 2º PO. O cálculo do PRI (Pain Rating Index), do MPQ-SF, para o agrupamento sensitivo (PRI-S), afetivo (PRI-A) e total (PRI-T) mostrou redução dos escores ao longo dos 4 dias PO (p<0,001). A correlação entre os escores de intensidade de dor e do PRI, nos 4 dias PO, foi positiva e significativa tanto para o PRI-S (0,52-0,34; p<0,001), PRI-A (0,52-0,30; p<0,001) como para o PRI-T (0,56-0,36; p<0,001). A dor pós-operatória ao repouso teve intensidade compatível com aquela observada em outros estudos, porém, à inspiração profunda ainda é intensa, podendo gerar maiores prejuízos na pronta recuperação dos clientes. Embora não associada significativamente à intensidade de dor, ressalta-se que todos os clientes apresentaram algum grau de ansiedade, estímulo natural que pode influenciar o sistema endógeno de modulação da dor, podendo exacerbar a dor. Qualitativamente a dor foi descrita por palavras do agrupamento sensitivo e afetivo do MPQ, apontando a multidimensionalidade da experiência dolorosa. Ressalta-se a importância da avaliação/mensuração e registro sistemático da dor pós-operatória, como quesitos fundamentais para a identificação precisa de complicações e a avaliação de intervenções para seu alívio.