Comparación de la eficacia del manejo analgésico habitual vs manejo analgésico habitual más infiltración de anestésico local en plano muscular en el postoperatorio inmediato de la cirugía abierta de próstata

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dc.contributor.advisorVillareal Trujillo, Nicolás
dc.contributor.advisorCamacho López, Paul Anthony
dc.contributor.apolounabCamacho López, Paul Anthony [paul-anthony-camacho-lópez]spa
dc.contributor.authorDiaz Rueda, Hernán Darío
dc.contributor.cvlacVillareal Trujillo, Nicolás [0001691724]spa
dc.contributor.cvlacCamacho López, Paul Anthony [0000323578]spa
dc.contributor.googlescholarCamacho López, Paul Anthony [es&oi=ao]spa
dc.contributor.orcidDíaz Rueda, Hernán Darío [0009-0001-5578-9454]spa
dc.contributor.orcidVillareal Trujillo, Nicolás [0000-0002-5974-8035]spa
dc.contributor.orcidCamacho López, Paul Anthony [0000-0002-6233-9582]spa
dc.coverage.campusUNAB Campus Bucaramangaspa
dc.coverage.spatialBucaramanga (Santander, Colombia)spa
dc.date.accessioned2025-02-28T14:56:20Z
dc.date.available2025-02-28T14:56:20Z
dc.date.issued2025-02-27
dc.degree.nameEspecialista en Urologíaspa
dc.description.abstractEsta investigación evalúa la eficacia de la infiltración de anestésicos locales durante la cirugía de próstata abierta para mejorar el control del dolor postoperatorio. Se realizó un estudio prospectivo con 89 pacientes, mostrando que aquellos sometidos a prostatectomía simple reportaron un mayor dolor en las primeras horas postoperatorias en comparación con los de prostatectomía radical, aunque no se observaron diferencias significativas en el uso de analgésicos de rescate. A pesar de los resultados que sugieren beneficios en la reducción del dolor, las limitaciones del estudio, especialmente la falta de un grupo control con placebo, impiden generalizar las conclusiones. Se concluye que la infiltración de anestésicos locales es un procedimiento seguro y efectivo, aunque se requieren estudios más controlados para validar estos hallazgos.spa
dc.description.abstractenglishThis investigation evaluates the effectiveness of local anesthetic infiltration during open prostate surgery to improve postoperative pain control. A prospective study was conducted with 89 patients, showing that those undergoing simple prostatectomy reported greater pain in the first postoperative hours compared to those undergoing radical prostatectomy, although no significant differences were observed in the use of rescue analgesics. Despite the results suggesting benefits in pain reduction, the limitations of the study, especially the lack of a placebo control group, prevent the conclusions from being generalized. It is concluded that the infiltration of local anesthetics is a safe and effective procedure, although more controlled studies are required to validate these findings.spa
dc.description.degreelevelEspecializaciónspa
dc.description.learningmodalityModalidad Presencialspa
dc.description.tableofcontents1. RESUMEN 2. JUSTIFICACIÓN 3. MARCO TEÓRICO 4. ESTADO DEL ARTE 5. OBJETIVOS a. OBJETIVO GENERAL b. OBJETIVOS ESPECÍFICOS 6. METODOLOGÍA 7. CONSIDERACIONES ÉTICAS 8. RESULTADOS 9. DISCUSIÓN 10. CONCLUSIONES 11. BIBLIOGRAFÍAspa
dc.format.mimetypeapplication/pdfspa
dc.identifier.instnameinstname:Universidad Autónoma de Bucaramanga - UNABspa
dc.identifier.reponamereponame:Repositorio Institucional UNABspa
dc.identifier.repourlrepourl:https://repository.unab.edu.cospa
dc.identifier.urihttp://hdl.handle.net/20.500.12749/28521
dc.language.isospaspa
dc.publisher.facultyFacultad Ciencias de la Saludspa
dc.publisher.grantorUniversidad Autónoma de Bucaramanga UNABspa
dc.publisher.programEspecialización en Urologíaspa
dc.publisher.programidEURO-1271
dc.relation.referencesAmid PK, Shulman AG, Lichtenstein IL. Local Anesthesia for Inguinal Hernia Repair Step-by-Step Procedure. 1994.spa
dc.relation.referencesDecker H, Wu CL, Wick E. Multimodal Pain Control in Surgery 2020. Vol. 55, Advances in Surgery. Academic Press Inc.; 2021. p. 147-57.spa
dc.relation.referencesHornberger J, Chhatwal J. Opioid Misuse: A Global Crisis. Vol. 24, Value in Health. Elsevier Ltd; 2021. p. 145-6.spa
dc.relation.referencesALERTA INFORMATIVA ACERCA DEL USO DE SUSTANCIAS Y PREPARADOS CON ACTIVIDAD PSICOACTIVA UTILIZADAS PARA EL MANEJO DEL DOLOR (OPIOIDES) [Internet]. Disponible en: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisisspa
dc.relation.referencesEllis JL, Pryor JJ, Mendez M, Sarmiento AS, Perito P, Simhan J. Pain Management Strategies in Contemporary Penile Implant Recipients. Curr Urol Rep. marzo de 2021;22(3):17spa
dc.relation.referencesEllis J, Higgins A, Simhan J. Pain management strategies in penile implantation. Vol. 22, Asian Journal of Andrology. Wolters Kluwer Medknow Publications; 2020. p. 34-8spa
dc.relation.referencesXie D, Nicholson M, Azaiza M, Gheiler V, Lopez I, Nehrenz GM, et al. Effect of operative local anesthesia on postoperative pain outcomes of inflatable penile prosthesis: prospective comparison of two medications. Int J Impot Res. junio de 2018;30(3):93-6spa
dc.relation.referencesCotta BH, Welliver C, Brahmamdam A, Bednarchik CL, Dynda D, Köhler TS. Long- acting liposomal bupivacaine decreases inpatient narcotic requirements in men undergoing penile prosthesis implantation. Turk Uroloji Derg. diciembre de 2016;42(4):230-4spa
dc.relation.referencesRaynor MC, Smith A, Vyas SN, Selph JP, Carson CC. Dorsal Penile Nerve Block Prior to Inflatable Penile Prosthesis Placement: A Randomized, Placebo-Controlled Trial. J Sex Med. 1 de noviembre de 2012;9(11):2975-9spa
dc.relation.referencesZayed M, Allers K, Hoffmann F, Bantel C. Transversus abdominis plane block in urological procedures: A systematic review and meta-analysis. Eur J Anaesthesiol. julio de 2021;38(7):758-67spa
dc.relation.referencesAndrade C, Sejnaui J, Ardila E, Caicedo J, Moyano G, Daza F, et al. Bloqueo anestésico con bupivacaína del espacio preperitoneal para la analgesia en prostatectomía laparoscópica. Rev Urol Colomb. 2012;XXI(2):13-21spa
dc.relation.referencesKelly DJ, Ahmad M, Brull SJ. Preemptive analgesia I: physiological pathways and pharmacological modalities. Can J Anesth Can Anesth. noviembre de 2001;48(10):1000-10spa
dc.relation.referencesCohen RH, Perl ER. Contributions of Arachidonic Acid Derivatives and Substance P to the Sensitization of Cutaneous Nociceptors [Internet]. Vol. 64, JOURNALOF ’NEUROPHYSIOLWY. 1990. Disponible en: www.physiology.org/journal/jnspa
dc.relation.referencesLevine JD, Fields HL, Basbaum2v4 AI. Peptides and the Primary Afferent Nociceptor. Vol. 13, The Journal of Neuroscience. 1993. p. 2273-2266.spa
dc.relation.referencesBirrell GJ, McQueen DS, Iggo A, Coleman RA, Grubb BD. PGI2-induced activation and sensitization of articular mechanonociceptors. Neurosci Lett. marzo de 1991;124(1):5-8spa
dc.relation.referencesWalker K, Perkins M, Dray A. KININS AND KININ RECEPTORS IN THE NERVOUS SYSTEM. Vol. 26, Neurochem. Int. 1995. p. 1-16spa
dc.relation.referencesHan L, Dong X. Itch mechanisms and circuits. Annu Rev Biophys. 2014;43(1):331-55spa
dc.relation.referencesDray A. Inflammatory mediators of pain. Vol. 75, British Journal of Anaesthesia. 1995. p. 125-31spa
dc.relation.referencesTaylor A, McLeod G. Basic pharmacology of local anaesthetics. Vol. 20, BJA Education. Elsevier Ltd; 2020. p. 34-41.spa
dc.relation.referencesStandring S. Anterior abdominal wall. En: Gray’s Anatomy. 42.a ed. Elsevier Ltd; p. 1122-36spa
dc.relation.referencesRozen WM, Tran TMN, Ashton MW, Barrington MJ, Ivanusic JJ, Taylor GI. Refining the course of the thoracolumbar nerves: A new understanding of the innervation of the anterior abdominal wall. Clin Anat. 2008;21(4):325-33spa
dc.relation.referencesChin KJ, McDonnell JG, Carvalho B, Sharkey A, Pawa A, Gadsden J. Essentials of our current understanding: Abdominal wall blocks. Vol. 42, Regional Anesthesia and Pain Medicine. Lippincott Williams and Wilkins; 2017. p. 133-83spa
dc.relation.referencesTsai HC, Yoshida T, Chuang TY, Yang SF, Chang CC, Yao HY, et al. Transversus Abdominis Plane Block: An Updated Review of Anatomy and Techniques. Vol. 2017, BioMed Research International. Hindawi Limited; 2017spa
dc.relation.referencesQazi N, Bhat W, Iqbal M, Wani A, Gurcoo S, Rasool S. Postoperative analgesic efficacy of bilateral transversus abdominis plane block in patients undergoing midline colorectal surgeries using ropivacaine: A randomized, double-blind, placebo-controlled trial. Anesth Essays Res. 2017;11(3):767spa
dc.relation.referencesBhattacharjee S, Ray M, Ghose T, Maitra S, Layek A. Analgesic efficacy of transversus abdominis plane block in providing effective perioperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled trial. J Anaesthesiol Clin Pharmacol. 2014;30(3):391spa
dc.relation.referencesMcDonnell JG, Curley G, Carney J, Benton A, Costello J, Maharaj CH, et al. The Analgesic Efficacy of Transversus Abdominis Plane Block After Cesarean Delivery: A Randomized Controlled Trial. Anesth Analg. enero de 2008;106(1):186-91spa
dc.relation.referencesAbdallah FW, Halpern SH, Margarido CB. Transversus abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis. Br J Anaesth. noviembre de 2012;109(5):679-87spa
dc.relation.referencesMilone M, Di Minno MND, Musella M, Maietta P, Salvatore G, Iacovazzo C, et al. Outpatient inguinal hernia repair under local anaesthesia: feasibility and efficacy of ultrasound-guided transversus abdominis plane block. Hernia. diciembre de 2013;17(6):749-55spa
dc.relation.referencesCho S, Kim YJ, Kim DY, Chung SS. Postoperative analgesic effects of ultrasound- guided transversus abdominis plane block for open appendectomy. J Korean Surg Soc. 2013;85(3):128spa
dc.relation.referencesRafi A. Abdominal field block: a new approach via the lumbar triangle. Anesthesia. 2001;56(10):1024-6.spa
dc.relation.referencesMcdonnell J, Odonnell B, Farrell T, Gough N, Tuite D, Power C, et al. Transversus Abdominis Plane Block: A Cadaveric and Radiological Evaluation. Reg Anesth Pain Med. septiembre de 2007;32(5):399-404spa
dc.relation.referencesHebbard PD, Barrington MJ, Vasey C. Ultrasound-Guided Continuous Oblique Subcostal Transversus Abdominis Plane Blockade: Description of Anatomy and Clinical Technique. Reg Anesth Pain Med. septiembre de 2010;35(5):436-41spa
dc.relation.referencesShibata Y, Sato Y, Fujiwara Y, Komatsu T. Transversus Abdominis Plane Block. Anesth Analg. 2007;105(3):883spa
dc.relation.referencesAbdallah FW, Laffey JG, Halpern SH, Brull R. Duration of analgesic effectiveness after the posterior and lateral transversus abdominis plane block techniques for transverse lower abdominal incisions: A meta-analysis. Vol. 111, British Journal of Anaesthesia. Oxford University Press; 2013. p. 721-35spa
dc.relation.referencesMukherjee A, Guhabiswas R, Kshirsagar S, Rupert E. Ultrasound guided oblique subcostal transversus abdominis plane block: An observational study on a new and promising analgesic technique. Vol. 60, Indian Journal of Anaesthesia. Indian Society of Anaesthetists; 2016. p. 284-6spa
dc.relation.referencesFavuzza J, Delaney CP. Laparoscopic-guided transversus abdominis plane block for colorectal surgery. Dis Colon Rectum. marzo de 2013;56(3):389-91spa
dc.relation.referencesBharti N, Kumar P, Bala I, Gupta V. The efficacy of a novel approach to transversus abdominis plane block for postoperative analgesia after colorectal surgery. Anesth Analg. 2011;112(6):1504-8spa
dc.relation.referencesOwen DJ, Harrod I, Ford J, Luckas M, Gudimetla V. The surgical transversus abdominis plane block - A novel approach for performing an established technique. BJOG Int J Obstet Gynaecol. enero de 2011;118(1):24-7.spa
dc.relation.referencesLapmahapaisan S, Tantemsapya N, Aroonpruksakul N, Maisat W, Suraseranivongse S. Efficacy of surgical transversus abdominis plane block for postoperative pain relief following abdominal surgery in pediatric patients. Paediatr Anaesth. junio de 2015;25(6):614-20spa
dc.relation.referencesZhong T, Wong KW, Cheng H, Ojha M, Srinivas C, McCluskey SA, et al. Transversus abdominis plane (TAP) catheters inserted under direct vision in the donor site following free DIEP and MS-TRAM breast reconstruction: A prospective cohort study of 45 patients. J Plast Reconstr Aesthet Surg. marzo de 2013;66(3):329-36spa
dc.relation.referencesAraco A, Pooney J, Araco F, Gravante G. Transversus abdominis plane block reduces the analgesic requirements after abdominoplasty with flank liposuction. Ann Plast Surg. octubre de 2010;65(4):385-8spa
dc.relation.referencesRosenblatt M. Uptodate; 2024. Abdominal nerve block techniques. Disponible en: www.uptodate.com/contents/abdominal-nerve-block- techniques/print?search=Abdominal%20nerve%20block%20techniques%20&source=s earch_result&selectedTitle=1%7E150&usage_type=default&display_rank=1spa
dc.relation.referencesFerguson S, Thomas V, Lewis I. The rectus sheath block in paediatric anaesthesia: new indications for an old technique? Pediatr Anesth. diciembre de 1996;6(6):463-6.spa
dc.relation.referencesSmith BE, Suchak M, Siggins D, Challands J. Rectus sheath block for diagnostic laparoscopy. Anaesthesia. noviembre de 1988;43(11):947-8spa
dc.relation.referencesKopacz D. Regional anesthesia of the trunk. En: Regional Anesthesia and Analgesia. W.B. Saunders; 1996spa
dc.relation.referencesDe Jose Maria B, Götzens V, Mabrok M. Ultrasound‐guided umbilical nerve block in children: a brief description of a new approach. Pediatr Anesth. enero de 2007;17(1):44-50spa
dc.relation.referencesWillschke H, Bösenberg A, Marhofer P, Johnston S, Kettner SC, Wanzel O, et al. Ultrasonography-guided rectus sheath block in paediatric anaesthesia—a new approach to an old technique. Br J Anaesth. agosto de 2006;97(2):244-9spa
dc.relation.referencesBagenal J, Horsnell J, Loader J, West D. Rectus sheath catheterisation: a novel method of placement. Ann R Coll Surg Engl. septiembre de 2013;95(6):443-4spa
dc.relation.referencesCornish P, Deacon A. RECTUS SHEATH CATHETERS FOR CONTINUOUS ANALGESIA AFTER UPPER ABDOMINAL SURGERY. ANZ J Surg. enero de 2007;77(1-2):84-84spa
dc.relation.referencesCrosbie EJ, Massiah NS, Achiampong JY, Dolling S, Slade RJ. The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique. Eur J Obstet Gynecol Reprod Biol. febrero de 2012;160(2):196-200spa
dc.relation.referencesElkassabany N, Ahmed M, Malkowicz SB, Heitjan DF, Isserman JA, Ochroch EA. Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: a prospective, randomized, double-blinded study. J Clin Anesth. septiembre de 2013;25(6):459-65spa
dc.relation.referencesO’Donnell BD. The Transversus Abdominis Plane (TAP) block in open retropubic prostatectomy [8]. Reg Anesth Pain Med. 2006;31(1):91spa
dc.relation.referencesDal Moro F, Aiello L, Pavarin P, Zattoni F. Ultrasound-guided transversus abdominis plane block (US-TAPb) for robot-assisted radical prostatectomy: a novel ‘4-point’ technique—results of a prospective, randomized study. J Robot Surg. febrero de 2019;13(1):147-51spa
dc.relation.referencesRoebuck E, Beano H, Robinson M, Edwards D, Worrilow WM, Sinks A, et al. Surgeon-administered Transversus Abdominis Plane (TAP) Block is Associated With Decreased Opioid Usage and Length of Stay Following Radical Cystectomy. Urology. marzo de 2022;161:135-41spa
dc.relation.referencesFaraj KS, Edmonds VS, Snider SL, Bunn WD, Tyson MD. Timing of perioperative transversus abdominis plane block at the time of radical cystectomy does not affect perioperative outcomes. Int Urol Nephrol. octubre de 2021;53(10):2019-25spa
dc.relation.referencesHosgood SA, Thiyagarajan UM, Nicholson HFL, Jeyapalan I, Nicholson ML. Randomized Clinical Trial of Transversus Abdominis Plane Block Versus Placebo Control in Live-Donor Nephrectomy. Transplantation. 15 de septiembre de 2012;94(5):520-5spa
dc.relation.referencesAniskevich S, Taner CB, Perry DK, Robards CB, Porter SB, Thomas C, et al. Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: A randomized, placebo-controlled trial. Local Reg Anesth. abril de 2014;7(1):11-6.spa
dc.relation.referencesCan MG, Göz R, Berber İ, Kaspar Ç, Çakır Ü. Ultrasound/laparoscopic camera-guided transversus abdominis plane block for renal transplant donors: A randomized controlled trial. Ann Transplant. julio de 2015;20:418-23spa
dc.relation.referencesDutton TJ, McGrath JS, Daugherty MO. Use of rectus sheath catheters for pain relief in patients undergoing major pelvic urological surgery. BJU Int. 2014;113(2):246-53spa
dc.relation.referencesShim JW, Cho YJ, Kim M, Hong SH, Moon HW, Hong SH, et al. Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot- assisted laparoscopic prostatectomy: a prospective, observational clinical study. BMC Anesthesiol. diciembre de 2020;20(1)spa
dc.relation.referencesShim JW, Jung S, Moon HW, Lee JY, Park J, Lee HM, et al. Rectus sheath block for acute pain management after robot-assisted laparoscopic prostatectomy. Asian J Surg. 2021;spa
dc.relation.referencesShahait M, Yezdani M, Katz B, Lee A, Yu SJ, Lee DI. Robot-Assisted Transversus Abdominis Plane Block: Description of the Technique and Comparative Analysis. J Endourol. marzo de 2019;33(3):207-10spa
dc.relation.referencesTaninishi H, Matsusaki T, Morimatsu H. Transversus Abdominis Plane Block Reduced Early Postoperative Pain after Robot-assisted Prostatectomy: a Randomized Controlled Trial. Sci Rep. 28 de febrero de 2020;10(1):3761spa
dc.relation.referencesCacciamani GE, Menestrina N, Pirozzi M, Tafuri A, Corsi P, Marchi DD, et al. Impact of Combination of Local Anesthetic Wounds Infiltration and Ultrasound Transversus Abdominal Plane Block in Patients Undergoing Robot-Assisted Radical Prostatectomy: Perioperative Results of a Double-Blind Randomized Controlled Trial. J Endourol. abril de 2019;33(4):295-301.spa
dc.relation.referencesBatley SE, Prasad V, Vasdev N, Mohan-S G. Post-Operative Pain Management in Patients Undergoing Robotic Urological Surgery. Curr Urol. febrero de 2016;9(1):5-11spa
dc.relation.referencesSkjelsager A, Ruhnau B, Kistorp TK, Kridina I, Hvarness H, Mathiesen O, et al. Transversus abdominis plane block or subcutaneous wound infiltration after open radical prostatectomy: a randomized study. Acta Anaesthesiol Scand. abril de 2013;57(4):502-8spa
dc.relation.referencesWu CL, Partin AW, Rowlingson AJ, Kalish MA, Walsh PC, Fleisher LA. Efficacy of continuous local anesthetic infusion for postoperative pain after radical retropubic prostatectomy. Urology. agosto de 2005;66(2):366-70spa
dc.relation.referencesMaquoi I, Joris JL, Dresse C, Vandenbosch S, Venneman I, Brichant J ‐F., et al. Transversus abdominis plane block or intravenous lignocaine in open prostate surgery: a randomized controlled trial. Acta Anaesthesiol Scand. noviembre de 2016;60(10):1453-60spa
dc.relation.uriapolohttps://apolo.unab.edu.co/en/persons/paul-anthony-camacho-l%C3%B3pezspa
dc.rights.accessrightsinfo:eu-repo/semantics/openAccessspa
dc.rights.creativecommonsAtribución-NoComercial-SinDerivadas 2.5 Colombia*
dc.rights.localAbierto (Texto Completo)spa
dc.rights.urihttp://creativecommons.org/licenses/by-nc-nd/2.5/co/*
dc.subject.keywordsMedical sciencesspa
dc.subject.keywordsHealth sciencesspa
dc.subject.keywordsUrologyspa
dc.subject.keywordsMedicinespa
dc.subject.keywordsLocal anestheticspa
dc.subject.keywordsOpen prostatectomyspa
dc.subject.keywordsPostoperative painspa
dc.subject.keywordsAnalgesicsspa
dc.subject.keywordsPostoperative painspa
dc.subject.keywordsSurgeryspa
dc.subject.keywordsPain (Treatment)spa
dc.subject.keywordsSurgery (Complications)spa
dc.subject.lembUrologíaspa
dc.subject.lembMedicinaspa
dc.subject.lembCiencias médicasspa
dc.subject.lembAnalgésicosspa
dc.subject.lembDolor postoperatoriospa
dc.subject.lembCirugíaspa
dc.subject.lembDolor (Tratamiento)spa
dc.subject.lembCirugía (Complicaciones)spa
dc.subject.proposalCiencias de la saludspa
dc.subject.proposalAnestésico localspa
dc.subject.proposalProstatectomía abiertaspa
dc.subject.proposalDolor postoperatoriospa
dc.titleComparación de la eficacia del manejo analgésico habitual vs manejo analgésico habitual más infiltración de anestésico local en plano muscular en el postoperatorio inmediato de la cirugía abierta de próstataspa
dc.title.translatedComparison of the efficacy of usual vs analgesic management usual analgesic management plus anesthetic infiltration local muscular plane in the immediate postoperative period of the open prostate surgeryspa
dc.type.coarhttp://purl.org/coar/resource_type/c_bdcc
dc.type.coarversionhttp://purl.org/coar/version/c_ab4af688f83e57aaspa
dc.type.driverinfo:eu-repo/semantics/masterThesis
dc.type.hasversioninfo:eu-repo/semantics/acceptedVersion
dc.type.localTesisspa
dc.type.redcolhttp://purl.org/redcol/resource_type/TM

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