Abstract Introduction Burns are a common trauma that cause acute severe pain in up to 80% of patients. The objective of this narrative review is to evaluate the efficacy of opioids, non-steroidal anti-inflammatory drugs, paracetamol, gabapentinoids, ketamine, and lidocaine in the treatment of acute pain in burn victims. Methodology The databases explored were PubMed, Embase, ClinicalTrials, and OpenGrey. The included randomized, controlled clinical trials assessed the analgesic efficacy of these drugs on hospitalized patients, had no age limit, patients were in the acute phase of the burn injury and were compared to placebo or other analgesic drugs. Studies describing deep sedation, chronic opioid use, chronic pain, and patients taken to reconstructive surgeries were excluded. The Jadad scale was used to evaluate quality. Results Six randomized controlled clinical trials (397 patients) that evaluated the analgesic efficacy of fentanyl (n = 2), nalbuphine (n = 1), ketamine (n = 1), gabapentin (n = 1), and lidocaine (n = 1) to treat post-procedural pain were included. Fentanyl, nalbuphine, and ketamine were effective, while lidocaine was associated with a slight increase in reported pain and gabapentin showed no significant differences. Two studies were of high quality, one was of medium high quality, and three were of low quality. No studies on the efficacy of NSAIDs or paracetamol were found. Conclusion Evidence of efficacy is very limited. Fentanyl, nalbuphine, and ketamine seem to be effective for controlling acute pain in burn patients, whereas gabapentin and lidocaine did not show any efficacy.

Abstract Background: Analgesia by specialists with formal training in pain management could be more effective, to find out, the results of a team of an acute pain service will be determined. Methods: Retrospective study (n = 108) of post-operative (POP) analgesia; two evaluations were taken: before starting analgesics in the immediate POP period and the second at 24 h. A multivariate analysis was performed to establish independent risk factors associated with the effectiveness of the treatment. Results: The effectiveness was 81.48% at 24 h. The risk factors associated with poor management effectiveness were: a comorbidity, prevalence ratio (PR) = 1.22; fibromyalgia (PR = 8.47), and cancer (PR = 2.47). The duration of surgery was associated with poor control PR = 1.10 for each hour elapsed. Protective factors for poor pain control: administration of non-steroidal anti-inflammatory drugs during the POP period (PR = 0.11) and use of analgesia controlled by the patient (PR = 0.29). Conclusion: POP pain relief is multifactorial; the participation of specialists was very effective. Identification of risk factors led to closer follow-up.

Resumen Objetivo: La analgesia por especialistas con entrenamiento formal en manejo del dolor podría ser más efectiva, para averiguarlo se determinarán los resultados de un servicio de dolor agudo. Material y métodos: Estudio retrospectivo (n = 108) de analgesia postoperatoria; se tomaron dos evaluaciones: antes de iniciar analgésicos en el postoperatorio inmediato y la segunda a las 24 horas. Se realizó un análisis multivariado para establecer los factores de riesgo independientes asociados con la efectividad del tratamiento. Resultados: La disminución promedio fue 51,75% en el primer día postoperatorio. La efectividad fue del 81,48% a las 24 horas. Los factores de riesgo asociados con la mala efectividad del manejo fueron: una comorbilidad, razón de prevalencia (RP) = 1,22; fibromialgia (RP = 8,47) y cáncer (RP = 2,47). La duración de la cirugía se asoció con un mal control PR = 1,10 por cada hora transcurrida. Factores protectores para el mal control del dolor: administración de antiinflamatorios no esteroideos durante el postoperatorio (RP = 0,11) y uso de analgesia controlada por el paciente (RP = 0,29). Conclusión: el alivio del dolor posoperatorio es multifactorial, la participación de especialistas fue muy eficaz. La identificación de los factores de riesgo condujo a un seguimiento más estrecho.

Resumen Introducción: El acceso a medicamentos esenciales, incluidos los opioides, es un componente del derecho a la salud. Objetivo: Identificar las barreras de disponibilidad y acceso a los opioides para dolor y cuidados paliativos. Métodos: Encuesta virtual a prescriptores colombianos. Las barreras de disponibilidad se analizaron para cada centro (distribución y/o dispensación) y las barreras de acceso se analizaron por tipo. Los análisis descriptivos se realizaron utilizando frecuencias relativas. La significancia dentro de categorías y regiones se midió utilizando la prueba exacta de Fischer. Resultados: De los 1208 prescriptores invitados, 806 (66.7%) respondieron la encuesta. Disponibilidad: el 76,43% reportó barreras. La barrera más citada fue la relacionada con las "farmacias autorizadas por las aseguradoras de salud", donde los opioides con frecuencia no están disponibles. Acceso: el 74,6% reportó barreras. Se citó con mayor frecuencia la "Dificultad para obtener la autorización de pago de medicamentos por parte de las aseguradoras". Se observaron diferencias significativas entre regiones y "costos" (p=0,02). La falta de coordinación entre las entidades de adquisición y distribución afecta la disponibilidad. La limitada conciencia y los procedimientos burocráticos afectan la accesibilidad. Conclusiones: Existen barreras de disponibilidad y acceso a los opioides en Colombia, las cuales están relacionadas con la estructura disponible para garantizar un suministro equitativo. Desde el punto de vista de los prescriptores, los problemas relacionados con la disponibilidad de las farmacias, la prescripción y el costo de los medicamentos, obstaculizan el tratamiento adecuado del dolor.

Abstract Introduction: Access to essential medicines, including opioids, is a component of the right to health. Objective: To identify barriers to opioid availability and accessibility for pain and palliative care. Methods: Online survey with Colombian prescribers. Availability barriers were analyzed for each facility (distribution and/or dispensing). Accessibility barriers were analyzed by type. Descriptive analyses were conducted using relative frequencies. Significance within categories and regions was measured using Fisher's exact test. Results: Out of 1,208 prescribers invited, 806 (66.7%) completed the survey. Availability: 76.43% reported barriers. The most cited barrier was "Pharmacies authorized by health insurance companies", where opioids are frequently unavailable. Accessibility: 74.6% reported barriers. Most frequently cited was "Difficulty securing payment authorization for medication from health insurance companies". Significant differences were observed in terms of regions and "Cost" (p=0.02). Lack of coordination among procuring and distributing agencies affects availability. Limited awareness and bureaucratic procedures affect accessibility. Conclusions: There are barriers to opioid availability and access in Colombia, related to the existing structure for guaranteeing equitable supply. From the perspective of healthcare providers, problems related to pharmacy availability, prescription and cost of medicines hinder pain treatment.

Resumen Introducción La prostatectomía es el tratamiento estándar para pacientes con cáncer de próstata localizado. Actualmente, la prostatectomía radical asistida por robot es ampliamente utilizada por sus ventajas en visualización, precisión y manipulación de los tejidos. Sin embargo, este abordaje requiere un manejo multidisciplinario, pues el enfoque analgésico y anestésico es fundamental para optimizar los desenlaces. Objetivo Describir los primeros casos de prostatectomía radical asistida por robot realizadas en un hospital universitario de cuarto nivel en Bogotá, Colombia. Metodología Estudio observacional en el cual se incluyeron todos los pacientes sometidos a prostatectomía radical asistida por robot (PRAR) en el hospital Fundación Santa Fe de Bogotá entre septiembre de 2015 y diciembre de 2019. Se excluyeron los pacientes con historia clínica incompleta. Se registraron los datos demográficos y se revisaron los eventos perioperatorios importantes. Resultados Se analizaron 301 pacientes. La edad media de pacientes sometidos a PRAR fue 61,4 ± 6,7 años. El tiempo quirúrgico promedio fue 205 ± 43 minutos y la pérdida sanguínea media fue 300 [200-400] mL. Solo 6 pacientes (2 %) requirieron transfusión. La edad y el IMC no mostraron una asociación relevante con los desenlaces clínicos. Conclusiones El adecuado abordaje perioperatorio en PRAR es importante para minimizar las complicaciones, las cuales en este estudio y en esta institución fueron infrecuentes.

Abstract Introduction Prostatectomy is the standard treatment for patients with clinically localized prostate cancer. Currently, robot-assisted radical prostatectomy (RARP) is widely used for its advantages, as it provides better visualization, precision, and reduced tissue manipulation. However, RARP requires a multidisciplinary approach in which anesthesia and analgesia management are especially important. Objective This study aims to describe our experience delivering anesthesia for the first cases of patients undergoing RARP in a teaching hospital in Bogotá, Colombia. Methodology An observational study was conducted. We included all patients undergoing RARP from September 2015 to December 2019 at Fundación Santa Fe de Bogotá. All patients with incomplete data were excluded. Patient demographics were recorded, and significant perioperative events were reviewed. Results A total of 301 patients were included. At our institution, the mean age for patients undergoing RARP was 61.4 ± 6.7 years. The mean operative time was 205 ± 43 min and mean blood loss was 300 [200400] mL. Only 6 (2%) patients required transfusion. Age and BMI were not associated with clinical outcomes. Conclusions An adequate perioperative approach in RARP is important to minimize complications, which in this study and in this institution were infrequent.

RESUMO INTRODUÇÃO: A avaliação da dor pós-operatória aguda é obrigatória para tratamentos eficientes. As trajetórias da dor podem ajudar os profissionais a melhorar os tratamentos. Tem sido sugerido que a falta de controle da dor no período pós-operatório imediato vai gerar maior intensidade dessa dor durante os dias seguintes de estadia no hospital. OBJETIVO: Determinar o relacionamento entre a dor durante a primeira hora pós-operatória e as 24 horas após a mesma. MÉTODOS: Lugar da pesquisa: Hospital universitário geral. Desenho do estudo: Foi feito um estudo analítico prospectivo operacional com pacientes submetidos a procedimentos cirúrgicos sob anestesia geral e que foram hospitalizados pelo menos 24 horas antes. Cinco avaliações de dor foram feitas na primeira hora na sala de recuperação, seguidas de três avaliações durante as primeiras 24 horas. Os declives das trajetórias da dor foram calculados e seu relacionamento entre elas foi analisado. RESULTADOS: Duzentos e trinta e quatro pacientes foram recrutados, 31,3% apresentaram dor não controlada no ingresso à sala de recuperação; no final das primeiras 24 horas após a cirurgia, 5,5% dos pacientes apresentaram dor não controlada. O score da primeira intensidade de dor na sala de recuperação teve uma correlação negativa com o declive da primeira hora (P1): rS = −0,657 (p=0,000). De maneira similar, o score na primeira intensidade de dor teve uma associação negativa com o declive da trajetória da dor durante a permanência no hospital (P2): rS = −0,141 (p=0,032). Quando comparados os dois declives, não foi encontrada uma correlação significativa: rS = −0,126. CONCLUSÃO: A trajetória da dor durante a primeira hora não prediz o comportamento da trajetória durante o primeiro dia após a cirurgia.

SUMMARY INTRODUCTION: Assessment of acute postoperative pain is mandatory for effective treatments. Pain trajectories may help professionals improve treatments. It has been suggested that uncontrolled pain in the immediate postoperative period generates higher pain intensities on the following days of hospital stay. OBJECTIVE: To determine the relationship between pain during the first postoperative hour and the first 24 postoperative hours. METHODS: Setting: a general university hospital. Study design: a prospective observational, analytical study of patients undergoing surgical procedures under general anesthesia and hospitalized for at least 24 hours. Five assessments of pain were carried out during the first hour in the recovery room followed by three assessments during the first 24 hours. The slopes of pain trajectories were calculated, and the relationship between them was analyzed. RESULTS: 234 patients were recruited, 31.3% had uncontrolled pain on arrival at the recovery room; at the end of the first 24 hours after surgery, 5.5% of the patients had uncontrolled pain. The first pain intensity score in the recovery room correlated negatively with the slope for the first hour (P1): rS = −0.657 (p = 0.000). Similarly, the first pain intensity score had a negative association with the pain trajectory slope during the hospital stay (P2): rS = −0.141 (p = 0.032). When comparing the two slopes, a nonsignificant negative correlation was found: rS = −0.126. CONCLUSIONS: the trajectory of pain during the first hour does not predict the behavior of the trajectory during the first day after surgery.

RESUMO INTRODUÇÃO: Os opioides interagem com ambos os sistemas imunes, inato e adaptativo, através de efeitos diretos sobre os receptores dos opioides localizados nas células imunes. As pesquisas neste assunto têm fornecido evidência da influência dos opioides sobre a resposta imune associada ao estresse cirúrgico. Os efeitos imunológicos dos opioides estão sendo pesquisados na atualidade, principalmente se eles determinam o resultado da cirurgia ou doença consequente devido a fatos importantes como infecção ou progressão do câncer. Essa revisão tem como alvo ver antecedentes em pesquisa relativa à influência dos receptores dos opioides no sistema imunológico, o efeito imunossupressor associado com opioides maiores durante o período peri-operatório e sua importância clínica. O objectivo da pesquisa foi revisar os efeitos dos opioides no sistema imunológico. MÉTODOS: Uma estrategia de procura foi dirigida na mídia PubMed, e no cadastro de Embase e The Cochrane, usando os termos “imunosuppressão”, “sistema imunológico”, “procedimentos cirúrgicos”, “analgésicos”, “opioides” e “cuidado peri-operatório”. RESULTADOS: O efeito imunosuppressor dos opioides foi identificado há mais de 30 anos. Os efeitos imunosupressores incluem sinalização e ação diretamente através das células imunes, mesmo com os linfócitos B e T, células NK, monócitos e macrófagos, também como ativando as vias de corrente do eixo hipotálamo- hipófise- adrenal (HPA) levando à produção de glucocorticoides imunossupresores no sistema nervoso periférico e simpático.

SUMMARY INTRODUCTION: Opioids interact with both innate and adaptive immune systems and have direct effects on opioid receptors located on immune cells. Research on this topic has provided evidence of the opioid influence on the immune response associated with surgical stress. The immunological effects of opioids are currently being investigated, particularly whether they influence the outcome of surgery or the underlying disease regarding important aspects like infection or cancer progression. This review addresses background research related to the influence of the opioid receptor on the immune system, the immunosuppressive effect associated with major opioids during the perioperative period, and their clinical relevance. The objective of the study was to review the effects of opioids on the immune system. Methods: A search strategy was conducted in PubMed, Embase, and the Cochrane databases using the terms “immunosuppression,” “immune system,” “surgical procedures,” “analgesics,” “opioids” and “perioperative care.” Results: The immunosuppressive effect of opioids was identified over 30 years ago. They include signaling and acting directly through immune cells, including B and T lymphocytes, NK cells, monocytes, and macrophages, as well as activating the downstream pathways of the hypothalamic-pituitary-adrenal (HPA) axis leading to the production of immunosuppressive glucocorticoids in the peripheral and sympathetic nervous system.

La angina refractaria es una condición clínica frecuente y debilitante en la que los síntomas persisten a pesar de la terapia médica óptima, cuando la intervención coronaria percutánea o la revascularización miocárdica es inviable o sus riesgos injustificados. La supervivencia de los pacientes con este diagnóstico es similar a la descrita para enfermedad isquémica coronaria crónica. Las opciones terapéuticas deben enfocarse en el alivio de la angina y en la mejoría de la calidad de vida. Recientemente se han propuesto varias alternativas para el tratamiento de la angina refractaria. Se reporta la experiencia de un grupo multidisciplinario en Colombia referente al implante de un neuroestimulador medular para el manejo de la angina refractaria.

La práctica clínica perioperatoria en Latinoamérica está influenciada por investigación generada y publicada en países desarrollados. Afortunadamente, las condiciones económicas cada vez más favorables para la ciencia en los países en vías de desarrollo, sumado al incremento en la visibilidad de nuestras publicaciones científicas, han desencadenado un incremento en el interés por mejorar los estándares de la calidad de la investigación local y a su vez en los trabajos de grado que se generan durante los estudios de posgrado en anestesiología. El presente documento es el resultado de la participación y discusión activa de los expositores y asistentes al evento: «Simposio de investigaciones en Anestesia: El camino para participar en la sociedad del conocimiento», organizado por la Sociedad Antioqueña de Anestesiología y Reanimación (SADEA) y la Sociedad Colombiana de Anestesiología y Reanimación (SCARE) en el año 2011. El objetivo del documento es plantear estrategias para ajustar, planificar y mejorar los procesos de investigación, así como la creación y la divulgación del conocimiento generado en anestesiología, medicina del dolor y cuidado intensivo para Colombia y países afines. Incluimos recomendaciones para los programas de posgrado, las instituciones prestadoras de salud y sociedades de anestesiología.

Perioperative clinical practice in Latin America is influenced by research developed and published in developed countries. Fortunately, the increasingly favorable economic conditions for science in the developing countries, in addition to the heightened visibility of our scientific publications has triggered greater interest in improving the quality standards of local research and of the graduate theses generated in the course of graduate studies in anesthesiology. This document is the result of the active participation and discussion among the speakers attending the «Symposium on Research in Anesthesia: the path to participation in the society of knowledge», organized by the Society of Anesthesiology and Resuscitation of Antioquia (SADEA) and the Colombian Society of Anesthesiology and Resuscitation (SCARE) in 2011. The purpose of the document is to discuss the strategies to adjust, plan and improve the research processes, as well as the creation and dissemination of knowledge generated in Anesthesiology, Pain Medicine and Intensive Care in Colombia and other developing countries. Recommendations have been included for graduate programs, health care providers and the societies of anesthesiology.

La atención médica al final de la vida es una situación a la que se enfrentan, cada vez con más frecuencia, los anestesiólogos. En esas circunstancias es esencial un enfoque médico y ético apropiado, con el fin de garantizar una calidad de muerte adecuada para el paciente y su familia. Se describe un caso de un paciente de 42 años, con cáncer de colon metastático, a quien se le inició sedación paliativa en presencia de síntomas refractarios, tanto físicos como existenciales. La práctica de la sedación como una opción terapéutica válida dentro de un contexto de atención paliativa eficiente, debe llevarse a cabo teniendo en cuenta los principios éticos y médicos relevantes. Así mismo, hay que reconocer las características propias de la formación del anestesiólogo, para que no se limite este tipo de atención en los pacientes al final de su vida. La atención médica al final de la vida es una situación que, cada vez con más frecuencia, enfrentamos los anestesiólogos. La sedación paliativa se establece como una opción terapéutica, basada en importantes criterios éticos y clínicos. En el momento de iniciarla hay que asegurarse del cumplimiento de dichos criterios, que deben evidenciarse frente al paciente, la familia y el grupo de salud.