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      ROUX-IN-Y GASTROJEJUNAL BYPASS: WHICH ANESTHETIC TECHNIQUE HAS BEST RESULTS? Translated title: BYPASS GASTROJEJUNAL EM Y-DE-ROUX: QUE TÉCNICA ANESTÉSICA APRESENTA MELHORES RESULTADOS?

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          Abstract

          Nausea and vomiting groups x moments

          ABSTRACT

          Background:

          As the number of bariatric operations increases, there is a greater interest in knowledge, experience and skills in the operative and anesthetic management of obese people. Anesthetic recovery is an important point in the therapeutic approach and less adverse effects delaying discharge of these patients are necessary to be kept in mind by the surgical team.

          Aim:

          To compare anesthetic-analgesic techniques in the opioid-sparing era through epidural administration of local anesthetic associated with low-dose morphine vs. clonidine and analyze the impact of analgesia on the effectiveness of postoperative recovery by comparing these two techniques.

          Methods:

          Randomized, double-blind clinical trial with 66 patients candidates for Roux-en-Y gastrojejunal bypass divided into two groups: morphine group and clonidine group. Multimodal analgesia included epidural anesthesia with 0.375% ropivacaine 20 ml at the eighth thoracic vertebra with the association of morphine (morphine group) at a dose of 15 mcg / kg or clonidine (clonidine group) at a dose of 1 mcg / kg.

          Results:

          The groups were homogeneous and statistical significance was found when analyzing the difference in pain between them in the first postoperative period. The pain was higher in the clonidine group, as in this period, analgesic rescue was also better in this group. In the other times, there was no significance in the differences regarding pain and rescue. The return of intestinal motility in the morphine group was earlier in the first postoperative period. Nausea, vomiting and hospital discharge did not show significant differences between groups.

          Conclusion:

          Epidural anesthesia with low-dose morphine allowed less pain during the entire hospital stay, with a positive impact on patient recovery.

          Translated abstract

          Náuseas e vômitos grupos x momentos

          RESUMO

          Racional:

          Com o aumento do número de operações bariátricas torna-se maior o interesse pelo conhecimento, experiência e habilidades no manejo operatório e anestésico de obesos. A recuperação anestésica é ponto importante na abordagem terapêutica e menos efeitos adversos que retardem a alta são necessários estar em mente da equipe cirúrgica.

          Objetivo:

          Comparar técnicas anestésico-analgésicas na era poupadora de opioides através da administração epidural de anestésico local associado à morfina em baixa dose vs. à clonidina e analisar o impacto da analgesia na efetividade da recuperação pós-operatória comparando as duas técnicas.

          Métodos:

          Ensaio clínico randomizado e duplo-cego com 66 pacientes candidatos ao bypass gastrojejunal em Y-de-Roux divididos em dois grupos: grupo morfina e grupo clonidina. A analgesia multimodal incluiu na anestesia epidural com ropivacaína 0,375% 20 ml na altura da oitava vértebra torácica a associação de morfina (grupo morfina) em dose de 15 mcg/kg ou de clonidina (grupo clonidina) na dose 1 mcg/kg.

          Resultados:

          Os grupos se mostraram homogêneos e foi encontrada significância estatística ao analisar a diferença da dor entre eles no primeiro pós operatório. A dor foi superior no grupo clonidina, como também neste período o resgate analgésico foi melhor neste grupo. Nos demais tempos não houve significância nas diferenças quanto à dor e resgate. O retorno da motilidade intestinal no grupo morfina foi mais precoce no primeiro pós-operatório. Náuseas, vômitos e a alta hospitalar não apresentaram diferenças significativas entre os grupos.

          Conclusão:

          A anestesia epidural com morfina em baixa dose permitiu menor dor durante todo internamento com impacto positivo em relação a recuperação dos pacientes.

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          Most cited references26

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          Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

          Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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            Multimodal General Anesthesia: Theory and Practice

            Balanced general anesthesia, the most common management strategy used in anesthesia care, entails the administration of different drugs together to create the anesthetic state. Anesthesiologists developed this approach to avoid sole reliance on ether for general anesthesia maintenance. Balanced general anesthesia uses less of each drug than if the drug were administered alone, thereby increasing the likelihood of its desired effects and reducing the likelihood of its side effects. To manage nociception intraoperatively and pain postoperatively, the current practice of balanced general anesthesia relies almost exclusively on opioids. While opioids are the most effective antinociceptive agents, they have undesirable side effects. Moreover, overreliance on opioids has contributed to the opioid epidemic in the United States. Spurred by concern of opioid overuse, balanced general anesthesia strategies are now using more agents to create the anesthetic state. Under these approaches, called “multimodal general anesthesia,” the additional drugs may include agents with specific central nervous system targets such as dexmedetomidine and ones with less specific targets, such as magnesium. It is postulated that use of more agents at smaller doses further maximizes desired effects while minimizing side effects. Although this approach appears to maximize the benefit-to-side effect ratio, no rational strategy has been provided for choosing the drug combinations. Nociception induced by surgery is the primary reason for placing a patient in a state of general anesthesia. Hence, any rational strategy should focus on nociception control intraoperatively and pain control postoperatively. In this Special Article, we review the anatomy and physiology of the nociceptive and arousal circuits, and the mechanisms through which commonly used anesthetics and anesthetic adjuncts act in these systems. We propose a rational strategy for multimodal general anesthesia predicated on choosing a combination of agents that act at different targets in the nociceptive system to control nociception intraoperatively and pain postoperatively. Because these agents also decrease arousal, the doses of hypnotics and/or inhaled ethers needed to control unconsciousness are reduced. Effective use of this strategy requires simultaneous monitoring of antinociception and level of unconsciousness. We illustrate the application of this strategy by summarizing anesthetic management for 4 representative surgeries.
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              Thoracic epidural analgesia and acute pain management.

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                Author and article information

                Journal
                Arq Bras Cir Dig
                Arq Bras Cir Dig
                abcd
                Arquivos Brasileiros de Cirurgia Digestiva : ABCD
                Colégio Brasileiro de Cirurgia Digestiva
                0102-6720
                2317-6326
                14 May 2021
                2021
                : 34
                : 1
                : e1530
                Affiliations
                [1 ]Postgraduate Program in Principles of Surgery, Mackenzie Evangelical College of Paraná/Medical Research Institute, Curitiba, PR, Brazil
                [2 ]Rocio Hospital, Campo Largo, PR, Brazil
                Author notes
                Correspondence: Paulo Afonso Nunes Nassif Email: paulonassif@ 123456terra.com.br

                Conflict of interest: none

                Author information
                http://orcid.org/0000-0002-7426-7133
                http://orcid.org/0000-0002-1752-5837
                http://orcid.org/0000-0002-1729-8419
                http://orcid.org/0000-0002-6133-3701
                http://orcid.org/0000-0002-4074-9521
                http://orcid.org/0000-0003-4711-6169
                http://orcid.org/0000-0002-3737-8395
                http://orcid.org/0000-0002-5790-9341
                http://orcid.org/0000-0002-3315-5039
                http://orcid.org/0000-0003-2676-3631
                Article
                00302
                10.1590/0102-672020200002e1530
                8121063
                34008703
                9fd4126b-ff04-47f7-bef3-4e283ec19e9f

                This is an open-access article distributed under the terms of the Creative Commons Attribution License

                History
                : 04 March 2020
                : 07 July 2020
                Page count
                Figures: 6, Tables: 8, Equations: 0, References: 21
                Categories
                Original Article

                obesity,bariatric,pain,eras,recovery,opioid,obesidade,bariátrica,dor,recuperação,opioide

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