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There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions., Competing Interests: Conflicts of Interest The authors declare no have conflicts of interest., (Copyright © 2024 Sociedade Brasileira de Anestesiologia. Published by Elsevier España S.L.U. All rights reserved.)

Objective: The main objective of this study was to compare stress and anxiety levels in children undergoing surgical procedures with or without parental presence at induction of anesthesia by measuring salivary cortisol levels and applying the mYPAS., Method: Quasi-randomized trial with children aged 5-12 year, with ASA physical status I, II, or III, undergoing elective surgery. According to parents' willingness, the pair were defined as accompanied or unaccompanied group. Chi-square, Fisher's exact tests, Student's t test, Mann-Whitney, Hodges-Lehman and Spearman's tests were used for statistical analyzes., Results: We included 46 children; 63% were preschool children mostly accompanied by their mothers (80%). The median mYPAS score was 37.5 (quartile range, 23.4-51.6) in unaccompanied children, and 55.0 (quartile range, 27.9-65.0) in accompanied children, with an estimated median difference of +11.8 (95% CI of 0 to 23.4; p = 0.044). There were no significant differences in the mean salivary cortisol levels., Conclusion: The level of anxiety was higher in accompanied children. There were no differences in salivary cortisol levels between both groups. Brazilian Registry of Clinical Trials (ReBEC): RBR-9wj4qvy.

Objective: Recent theoretical models posit that resilience acts as a resource/mechanism opposing pain catastrophizing and other vulnerability sources against pain adaptation. The aim of this study was to investigate the relationship between resilience, pain, and functionality in people living with fibromyalgia (FM)., Materials and Methods: We conducted a cross-sectional online survey of people participating in Brazilian fibromyalgia virtual support groups on Facebook in May 2018. Resilience was evaluated by the Connor-Davidson Resilience Scale. Average pain and the degree of interference of pain in the lives of participants (DIPLP) were assessed using the Brief Pain Inventory. The association between these 3 variables was evaluated through multivariable robust linear regression with adjustment for 21 potential confounders., Results: We included 2176 participants with FM. Resilience was associated with a decreased DIPLP (β: -0.38, 95% CI: -0.54 to -0.22, P <0.001) but not with average pain scores (β: -0.01, 95% CI: -0.18 to 0.16, P =0.93). A significant interaction between resilience and average levels of pain on the DIPLP was observed so that resilience showed a much stronger protective association among participants with average null-to-mild pain than among those with moderate and severe pain levels., Discussion: Our results provide evidence against beliefs that the pain of people with FM is related to low psychological resilience and shed light on the complex interrelationships between resilience, pain, and functionality. This research signals both the relevance and limits of resilience in the management of FM. Future studies evaluating behavioral interventions for FM should consider how those interventions interact with baseline pain levels and resilience., Competing Interests: L.A.T. conceived the study, was responsible for data collection, and drafted the first version of the manuscript. E.I.O.V. and L.A.T. analyzed the data, directly accessed the data, and verified the underlying data reported in the manuscript. The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier España S.L.U.)

Background: Nausea and vomiting are frequent complications of anesthesia in the postoperative period. Acupuncture at the pericardium point 6 (PC6) is known to be effective in preventing postoperative nausea and vomiting (PONV)., Objectives: The objective of the present study is to investigate the effects of acupuncture performed at the PC6 point in the prevention of PONV in women undergoing elective open hysterectomy under general inhalational anesthesia and to assess its association with plasma serotonin levels., Methods: 97 patients undergoing elective open hysterectomy were randomly divided into two groups: acupuncture group (bilateral acupuncture at PC6, n = 49), and a control group (no acupuncture, n = 48). All patients prophylactically received ondansetron and dexamethasone and, as rescue medication, metoclopramide in case of occurrence of PONV. The primary outcome evaluated was occurrence of nausea and vomiting within 24 hours after surgery. Serotonin plasma levels were measured before and after acupuncture prior to anesthesia induction. For the control group, the repeat measurement was performed 30 minutes after admission to the preoperative unit., Results: Acupuncture at PC6 significantly reduced the incidence of nausea (29.2% vs. 6.1%; p > 0.003), and the need of rescue medication (metoclopramide) (33.3% vs. 10.2%; p > 0.006), but not vomiting (4.2 vs. 4.1; p > 0.98). The plasma serotonin levels between control and acupuncture groups did not differ., Conclusion: This study shows that acupuncture at PC6 resulted in a lower incidence of postoperative nausea in patients undergoing hysterectomy.

Objective: The objective of this study was to evaluate the analgesic efficacy of a portable, disposable, and home self-applied transcutaneous electrical nerve stimulation (TENS) device during migraine attacks., Background: TENS has been used as a noninvasive treatment for migraine, but there are no reports on the outcomes following use of this treatment option for use at home during migraine attacks., Design and Methods: A double-blind, randomized controlled trial was conducted over 3 months, with monthly assessments. Active placebos (sham group) were in place and were allocated at a 1:1 ratio. Adult patients who had been diagnosed with migraine by a specialist were included. Pain intensity levels and functional disability were measured before and after the 20-min self-applied TENS intervention during the migraine attacks., Results: Seventy-four participants were randomly allocated to the sham and intervention groups. Although both groups of subjects reported lower pain scores, the intervention group showed a statistically significant reduction in pain scores compared to the sham group., Conclusion: In our controlled trial, the use of a self-applied, TENS device is safe and effective in relieving pain associated with migraine attacks. Participants in the intervention group showed a statistically significant improvement in pain and functional disability scores. TENS has been used as a noninvasive treatment for migraine, but there are no reports on the outcomes following use of this treatment option for use at home during migraine attacks. This double-blind, randomized controlled trial had 2 groups: active-placebo and intervention. Seventy-four participants were randomly allocated. Participants in the intervention group showed a statistically significant improvement in pain and functional disability scores., (© 2021 World Institute of Pain.)

Study Objective: This study aimed to evaluate the analgesic effects of a 5% lidocaine patch in acute postoperative pain after cesarean section., Design: This is a prospective, randomized, double-blind study., Setting: After surgery, active and placebo patches were applied in the operating room, and patients were evaluated during their stay at the postoperative recovery room and at the hospital ward., Patients: Seventy-two women (18 years of age or older and American Society of Anesthesiologists status II) scheduled for cesarean section under spinal anesthesia were enrolled in the study., Interventions: Patients were randomly assigned to an intervention or placebo group. According to the assigned group, a 5% lidocaine patch or a placebo patch was applied 1 cm above and below the Pfannenstiel incision after the surgery., Measurements: The primary outcome was the pain score, evaluated using an 11-point numerical verbal scale in the first 36 h postoperatively. Secondary outcomes were the quality of recovery 24 h after surgery, consumption of rescue opioids, and the presence of adverse effects., Main Results: Sixty-five women completed the study. The pain score was lower in the lidocaine group at 6 h (lidocaine group: 2.16 ± 1.71, placebo group: 3.21 ± 2.25; p = 0.031), 12 h (lidocaine: 1.58 ± 0.81, placebo: 2.24 ± 0.74; p = 0.001), 24 h (lidocaine: 0.74 ± 0.89, placebo: 1.94 ± 1.39; p < 0.0001), and 36 h (lidocaine: 0.48 ± 1.03, placebo: 1.68 ± 0.94; p = 0.001) after surgery. There were no differences in secondary outcomes during the follow-up period., Conclusion: The lidocaine patch reduced pain scores compared to placebo in the first 36 h after the surgery, despite no influence over opioid consumption, quality of recovery, or incidence of side effects., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Aims: Rocuronium may provide excellent onset time, but high doses are required for effective action. Several strategies have managed to shorten rocuronium onset time, including the use of Magnesium Sulphate (MgSO 4 )., Methods: One hundred and eighty patients were randomized into six groups according to rocuronium dose received (0.3, 0.6 or 1.2 mg.kg -1 ) and the administration of saline or MgSO 4 (60 mg.kg -1 ). Correlations between tissue perfusion and rocuronium onset time was determined by variations in perfusion index., Results: Median (quartiles) rocuronium onset times were 85.5 (74.0-92.0); 76.0 (52.0-87.0) and 50.0 (41.0-59.5) seconds for 0.3, 0.6 mg.kg -1 and 1.2 mg.kg -1 doses, respectively. MgSO 4 decreased rocuronium onset at doses of 0.3 mg.kg -1 (60.0 [48.0-74.3] seconds) and 0.6 mg.kg -1 (44.0 [39.0-49.0] seconds) but not at 1.2 mg.kg -1 (38.0 [33.5-56.3] seconds) (p < 0.001). Perfusion index variations in groups that received MgSO 4 were greater than in controls. A negative correlation between shorten onset and increased perfusion index was observed in rocuronium doses of 0.3 mg.kg -1 (r = -0.50; p < 0.001) and 0.6 mg.kg -1 (r = -0.424; p < 0.001), but not for 1.2 mg.kg -1 dose (r = -0.25; p = 0.07)., Conclusion: MgSO 4 reduces rocuronium onset time at doses of 0.3 mg.kg -1 and 0.6 mg.kg -1 being that the latter has a similar effect when compared to the dose of 1.2 mg.kg -1 , with or without the use of MgSO 4 . TRIAL REGISTRY AT: http://www.ensaiosclinicos.gov.br/ REGISTRY NUMBER: RBR-96CY3K., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Introduction: Including palliative care (PC) in overloaded medical curricula is a challenge, especially where there is a lack of PC specialists. We hypothesised that non-specialised rotations could provide meaningful PC learning when there are enough clinical experiences, with adequate feedback., Objective: Observe the effects of including PC topics in non-specialised placements for undergraduate medical students in two different medical schools., Design: Observational prospective study., Setting: Medical schools in Brazil., Participants: 134 sixth-year medical students of two medical schools., Methods: This was a longitudinal study that observed the development of Self-efficacy in Palliative Care (SEPC) and Thanatophobia (TS) in sixth-year medical students in different non-specialised clinical rotations in two Brazilian medical schools (MS1 and MS2). We enrolled 78 students in MS1 during the Emergency and Critical Care rotation and 56 students in MS2 during the rotation in Anaesthesiology. Both schools provide PC discussions with different learning environment and approaches., Primary Outcomes: SEPC and TS Scales were used to assess students at the beginning and the end of the rotations., Results: In both schools' students had an increase in SEPC and a decrease in TS scores., Conclusion: Non-specialised rotations that consider PC competencies as core aspects of being a doctor can be effective to develop SEPC and decrease TS levels., Competing Interests: Competing interests: GAMdB is a supervisor in MS2 and participates in collecting data., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background and Objectives: Advances in medicine, including anesthesiology and resuscitation, have made natural death increasingly rare. As a consequence, dysthanasia has become usual in a scenario for which there is not rationale. The present study aimed to assess the level of knowledge of Brazilian anesthesiologists on the principles of dysthanasia and orthothanasia. Thence, we studied the management preferences of these professionals, vis-à-vis those practices, as well as how medical school contributed to addressing death-related issues., Method: Quantitative approach, prospective and descriptive cohort that included 150 anesthesiologists, members of the Brazilian Society of Anesthesiology, and who were invited to participate by email. An online questionnaire containing 38 questions was prepared by the authors. The study was approved by the Instructional Research Ethics Committee., Results: Anesthesiologists, although claiming to know dysthanasia and orthothanasia, mostly acquired knowledge outside medical school. If faced with their own end of care, or of a patient or a loved one, they prefer orthothanasia, to die at home, prioritizing dignity. However, the specialists claimed to have already practiced dysthanasia, even when orthothanasia was the choice management, which caused them negative feelings. Almost all respondents stated that they did not have practical training in undergraduate school on how to face end-of-life issues, although they felt capable of identifying it. Most were not aware of Federal Council of Medicine Resolution 1.805/06 that makes practicing orthothanasia feasible. Anesthesiologists' religion or the political-administrative region of residence had no effect on their preferences., Conclusions: Anesthesiologists claim to have knowledge on dysthanasia and orthothanasia, but prefer, in the face of a terminally ill patient, to practice orthothanasia, although dysthanasia is usual, and results in frustration and indignation. The medical school curriculum is unsatisfactory in addressing death-related issues., (Copyright © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objective: This study aims to produce and validate the version of the instrument Amyotrophic Lateral Sclerosis-Specific Quality of Life-Short Form (ALSSQOL-SF) into Portuguese, adapted to the Brazilian cultural context., Methodology: It is a cross-cultural adaptation and validation study, carried out in two Brazilian Public Universities, in the period from March, 2017, to November, 2018, according to the six steps guidelines of cultural and linguistic adaptation proposed by Beaton et al. (Spine 25(24):3186-3191, 2000). The World Health Organization Quality of Life (WHOQOL-BREF) and the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS-R) were used for perform the validation. In order to analyze the correlations between the ALSSQOL-SF, WHOQOL-BREF, and ALSFRS-R scores, Spearman's correlation coefficients were calculated. The project was approved by the Research Ethics Committee of the two participating institutions., Result: All steps of the transcultural adaptation process were performed without intercurrence. The pilot test had the participation of 30 individuals, and the "Questionário Breve Específico de Qualidade de Vida para Pacientes com ELA (QVELA-20/Br)" tool was developed. During the validation phase, 100 patients were included, most of them were male (58%) with a median age of 59 years. The created version of the questionnaire are positively and strongly correlated with the WHOQOL-BREF and positively and weakly correlated with ALSFRS-R, as expected., Conclusion: The study produced and validated a version of the instrument ALSSQOL-SF into Portuguese that is adapted to the Brazilian cultural context.

Background: Myofascial pain syndrome is a common cause of musculoskeletal pain. The objective of this study was to evaluate the potential analgesic action of 8% capsaicin cream for topical use in patients with myofascial pain syndrome., Methods: Initially, cream formulations of PLA (Placebo) and CPS (Capsaicin 8%) were developed and approved according to the current requirements of the health authority agency. The 40 participating patients were randomly assigned to the PLA and CPS groups in a double-blind fashion. Before the creams were topically administered, according to the allocation group, the local anesthetic was used for a period of 50minutes directly in the area of interest. The cream was applied to the area of the skin over the trigger point, represented by the area with pain at palpation, in an amount of 10g for 30minutes in a circular area of 24 mm diameter. Subsequently, the cream was removed and the skin tolerability parameters were evaluated. The pain was measured before and during the formulation application, as well as at 1 hour, 7 days, 30 days, and 60 days after the procedure, evaluated using a verbal numerical scale (from 0 to 10: with 0=no pain and 10=worst pain imaginable)., Results: No patient in PLA Group had hyperemia or burning sensation at the site of application, while 85% of patients in CPS Group had hyperemia or burning sensation at 15minutes. These complaints disappeared 24hours after the cream was removed. The pain score in CPS Group decreased steadily up to the 60 th day of evaluation (p <0.0001)., Conclusion: Application of the formulations did not cause macroscopic acute or chronic skin lesions in patients, and the 8% capsaicin formulation was beneficial and well tolerated., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Postoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half-life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil-based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil-based total intravenous anesthesia., Methods: Forty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil-based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient-controlled analgesia pump. Self-reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery., Results: The mean difference between the sufentanil and control groups regarding morphine consumption in the post-anesthetic care unit and at 12, 24 and 48h after surgery were -7.2mg (95%CI: -12.5 to -2.1, p<0.001), -3.9mg (95%CI: -11.9 to 4.7, p=0.26), -0.6mg (95%CI: (-12.7 to 12.7, p=0.80), and -1.8mg (95%CI: (-11.6 to 15.6, p=0.94), respectively. Neither self-reported pain nor the incidence of adverse events were significantly different between groups at any time point., Conclusion: Our findings suggest that the administration of sufentanil during induction of remifentanil-based total intravenous anesthesia is associated with decreased early postoperative opioid consumption., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Competing Interests: Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Background and Objectives: As the number of people with tattoos has been increasing, anesthesiologists are more and more faced with the decision to perform a neuraxial blockage through tattooed skin. In this study, we evaluated the possibility of puncture through tattooed skin determines acute inflammatory changes in the meninges and spinal cord and later evolve into adhesive arachnoiditis., Method: Forty-two male rabbits were randomized into 3 groups of 14: G1, spinal puncture through non-tattooed skin and saline solution injection; G2, spinal puncture through tattooed skin and saline solution injection, captive for 30 days; G3, spinal puncture through tattooed skin and saline solution injection, captive for 360 days. The animals were anesthetized and ultrasound-guided spinal puncture was performed in the intervertebral spaces between S1 - S2. During the period of captivity, the animals were clinically assessed for sensitivity and motor function. After that, they were sacrificed and the lumbosacral portion of the spinal cord was excised for histological analysis., Results: No histological changes were found on group 1. Eleven animals from group two presented with foci of perivascular lymphocytic inflammatory infiltrate in the pia mater and/or arachnoid. In Group 3, eight rabbits presented with inflammatory changes in the meninges, which were associated with thickening and/or adhesion of the pia mater and arachnoid in some cases and five rabbits presented only thickening of pia-mater., Conclusions: Spinal puncture through tattooed skin of rabbits can trigger acute inflammatory changes in the meninges and after a prolonged period of observation evolve into adhesive arachnoiditis., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose of Review: The experience of a life crisis, such as the experience of end-of-life terminality whenever facing cancer can make the spiritual needs of patients clear. The goal of this revision was to synthesize the existing evidence regarding the spiritual needs of patients with cancer in palliative care., Recent Findings: An integrated revision of the literature was conducted regarding the database sources from PubMed, CINAHL, EMBASE, LILACS and Scopus, without publishing year restrictions. There were 16 primary studies included. A total of 1469 patients have been evaluated, whereas eight groups of spiritual needs have been identified: finding the meaning and purpose of life; finding the meaning in experiencing the disease; being connected to other people, God and nature; having access to religious/spiritual practices; physical, psychological, social and spiritual wellbeing; talking about death and the experience of dying; making the best out of their time; being independent and being treated like a normal person., Summary: It is essential to pay attention to patients' spiritual dimensions regarding palliative care. Therefore, patients' spiritual needs must be identified and remedied or mitigated. It is necessary to develop studies that find specific strategies and interventions for the treatment of these needs.

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.