José Eduardo Guimarães Pereira

Objective: We aimed to evaluate whether deep neuromuscular blockade (DNMB) improves surgical conditions and facilitates low-pressure pneumoperitoneum compared with moderate neuromuscular blockade (MNMB) during minimally invasive surgery. Data Sources: PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, Scopus, Web of Science, and LILACS were searched from inception through May 2026. Study Selection: Randomized controlled trials comparing DNMB versus MNMB in adults undergoing laparoscopic or robot-assisted surgery were included. Data Extraction: Two reviewers independently screened studies, extracted data, and assessed risk of bias using the revised Cochrane Risk of Bias tool (RoB 2). Certainty of evidence was evaluated using the GRADE approach. Primary Outcomes: Primary outcomes were surgical workspace quality and intra-abdominal pressure requirements. Secondary Outcomes: Secondary outcomes included postoperative abdominal pain at 24 h and referred shoulder pain. Data Synthesis: Seventeen randomized controlled trials involving 1512 patients were included. DNMB consistently improved surgical workspace conditions and facilitated lower pneumoperitoneum pressures compared with MNMB. Pooled analyses additionally suggested reductions in postoperative abdominal pain and referred shoulder pain in selected studies, although postoperative outcomes demonstrated greater heterogeneity across procedures and perioperative protocols. Conclusions: Current evidence suggests that the principal clinical value of DNMB during minimally invasive surgery is optimization of surgical exposure and facilitation of low-pressure pneumoperitoneum strategies. Benefits related to postoperative abdominal pain may occur in selected settings but appear less consistent across procedures.

Objective: To evaluate whether deep neuromuscular blockade (DNMB) improves surgical conditions and facilitates low-pressure pneumoperitoneum compared with moderate neuromuscular blockade (MNMB) during minimally invasive surgery. Data Sources PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, Scopus, Web of Science, and LILACS were searched from inception through May 2026. Study Selection Randomized controlled trials comparing DNMB versus MNMB in adults undergoing laparoscopic or robot-assisted surgery were included. Data Extraction Two reviewers independently screened studies, extracted data, and assessed risk of bias using the revised Cochrane Risk of Bias tool (RoB 2). Certainty of evidence was evaluated using the GRADE approach. Primary Outcomes: Primary outcomes were surgical workspace quality and intra-abdominal pressure requirements. Secondary Outcomes: Secondary outcomes included postoperative pain at 24 hours and referred shoulder pain. Data Synthesis: Seventeen randomized controlled trials involving more than 1700 patients were included. DNMB consistently improved surgical workspace conditions and facilitated lower pneumoperitoneum pressures compared with MNMB. Pooled analyses additionally suggested reductions in postoperative pain and referred shoulder pain in selected studies, although postoperative outcomes demonstrated greater heterogeneity across procedures and perioperative protocols. Conclusions: Current evidence suggests that the principal clinical value of DNMB during minimally invasive surgery is optimization of surgical exposure and facilitation of low-pressure pneumoperitoneum strategies. Benefits related to postoperative pain may occur in selected settings but appear less consistent across procedures.

Background: Opioid‐free anesthesia (OFA) has been proposed as a strategy to reduce opioid exposure and opioid‐related adverse events in laparoscopic surgery. However, evidence from randomized trials remains heterogeneous regarding pain control, postoperative nausea and vomiting (PONV), and opioid consumption. Methods: We performed a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing OFA with opioid‐based anesthesia (OBA) in adult patients undergoing elective laparoscopic surgery. Primary outcomes included postoperative pain scores (0–10 scale), PONV, and 24‐h opioid consumption. Secondary outcomes included hemodynamic events, recovery quality, and hospital length of stay. Results: Sixteen RCTs ( n = 1322) were included. OFA reduced PONV by approximately 40% (RR 0.60; 95% confidence interval [CI] 0.48–0.75) and modestly decreased postoperative opioid use by 6.4 mg morphine equivalents (95% CI −9.1 to −3.7). Pain scores during the first 24 h were similar between OFA and OBA (MD −0.3 on a 0–10 scale; 95% CI −0.7 to +0.1). Hemodynamic instability (bradycardia and hypotension) occurred more frequently with dexmedetomidine‐based regimens but was transient and clinically manageable. No differences were observed in recovery time or hospital length of stay. Conclusion: OFA provides clinically meaningful reductions in PONV and opioid exposure without compromising postoperative analgesia. These findings support OFA as a safe and effective alternative to OBA in laparoscopic surgery and a potential component of enhanced recovery pathways.

Introduction: Craniotomy, a common neurosurgical procedure, is frequently associated with substantial perioperative challenges and delayed recovery. While Enhanced Recovery After Surgery (ERAS) protocols have demonstrated clear benefits in multiple surgical fields, their application in neurosurgery, particularly elective craniotomy, remains emerging. Objective: This systematic review and meta-analysis aimed to evaluate the efficacy and safety of ERAS protocols in adult patients undergoing elective craniotomy, focusing on key outcomes such as length of hospital stay (LOS), postoperative pain, complications, and functional recovery. Methods: Following PRISMA guidelines, a comprehensive search was conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up to June 2025. Eligible studies included adult patients (≥18 years) undergoing elective craniotomy and compared ERAS protocols to conventional perioperative care. Primary outcomes were LOS, postoperative complications, pain, early oral intake, and early mobilization. Data extraction and risk of bias assessment (RoB 2.0) were independently performed by two reviewers. Results: Nine randomized controlled trials (RCTs), totaling 1453 patients, were included. Meta-analysis showed that ERAS protocols significantly reduced length of hospital stay (mean difference: −2.17 days; 95% CI: −2.92 to −1.42; p < 0.00001) and decreased the incidence of postoperative nausea and vomiting (odds ratio [OR]: 0.29; 95% CI: 0.19 to 0.44; I² = 0%). ERAS protocols were associated with higher odds of early mobilization (OR: 6.88; 95% CI: 3.46 to 13.68) and early oral intake (OR: 14.04; 95% CI: 7.80 to 25.26). Postoperative complications were significantly reduced in the ERAS group (OR: 0.49; 95% CI: 0.24 to 0.99; p = 0.048; I² = 0%). While early urinary catheter removal showed a favorable trend (OR: 13.48), high heterogeneity (I² = 95.7%) limits interpretability. Postoperative pain on day 1 did not differ significantly between groups (mean difference: −0.37; 95% CI: −2.38 to 1.63; p = 0.72). The overall risk of bias was rated low to moderate across studies. Conclusions: ERAS protocols in elective craniotomy are associated with shorter hospital stays, lower complication rates, reduced PONV, and earlier return to function, without increasing adverse events. These findings support broader implementation of ERAS in neurosurgical practice. Further multicenter RCTs are warranted to standardize and refine ERAS components for craniotomy.

Chronic non-cancer pain (CNCP) is among the clinical conditions that most challenge curative medicine due to its high therapeutic failure rates. In many cases, pain management teams are unable to identify a clear organic cause for the pain condition; in others, an etiological factor is found that can be attributed to the condition, but it is recognized, either promptly or after some years, that this organic substrate is insufficient to sustain the patient’s suffering for such a prolonged period; finally, there are cases in which the presumed organic cause of pain is corrected, yet the patient does not improve or does not improve as expected. The aim of this paper is to present a literature review on mental health aspects and the doctor-patient relationship involved in the management of patients with refractory CNCP. A systematic search and literature review methodology was employed, using the descriptors intractable pain, pain management, medical history, medication review, physician-patient relationship, and mental health evaluation in the Cochrane Central, PubMed, and LILACS databases, with no restrictions regarding study design, language, or publication date. Ten suggestions are presented as a result of the analysis of the included articles and the authors’ experience, some related to the semiological approach and others to the therapeutic follow-up of patients with CNCP. The suggestions presented may be useful in the management of refractory CNCP cases and should preferably be implemented before indicating invasive procedures.

A dor crônica não-oncológica (DCNO) está entre as condições clínicas que mais desafiam a medicina curativa, dadas as suas altas taxas de insucesso terapêutico. Em muitos casos, as equipes de tratamento de dor não conseguem delimitar uma clara causação orgânica para o quadro álgico; em outros, encontra-se um fator etiológico ao qual pode ser atribuído o quadro, mas se reconhece – de pronto ou com a delonga de alguns anos – que aquele substrato orgânico é insuficiente para perpetuar o sofrimento de um dado paciente por tanto tempo; finalmente, há casos em que se consegue corrigir a suposta causa orgânica da dor mas, mesmo assim, o paciente não melhora, ou não melhora na medida do esperado. O objetivo deste trabalho é apresentar uma revisão de literatura sobre aspectos de saúde mental e da relação médico-paciente intervenientes no manejo de pacientes com DCNO refratária. Utilizou-se metodologia de busca sistemática e revisão de literatura, com uso dos descritores intractable pain, pain management, medical history, medication review, physician-patient relationship, e mental health evaluation nas bases de dados Cochrane Central, PubMed e LILACS, sem restrições quanto a desenho do estudo, idioma ou data de publicação. Dez sugestões são apresentadas como resultado da análise dos artigos incluídos e da experiência dos autores, algumas relacionadas à abordagem semiológica e outras ao seguimento terapêutico dos pacientes com DCNO. As sugestões apresentadas podem ser úteis no manejo de casos refratários de DCNO, e deveriam ser implementadas preferentemente antes da indicação de procedimentos invasivos.

Objective: to study the effectiveness of type II pectoral nerve block (PEC II) for breast augmentation with submuscular implants by assessing opioid consumption and pain scale in the immediate postoperative period, from the post-anesthesia care unit (PACU) to 24 h postoperatively. Methods: A prospective, controlled, randomized, and double-blind study. Thirty-four patients were analyzed during the perioperative period and in the PACU, with one group receiving bilateral PEC II combined with general anesthesia and the control group receiving only general anesthesia. Results: There was no difference between the groups regarding demographic data, surgical and anesthetic times, or intraoperative opioid use. Opioid consumption in the control group was consistently higher at all the time intervals studied, with an average morphine consumption 38.7% greater. The largest variation in morphine consumption occurred at the fourth and sixth hours postoperatively. The greatest difference in postoperative pain was 36% higher in the control group compared to the intervention group. Conclusions: patients who underwent general anesthesia combined with PEC II had lower opioid consumption and a lower postoperative pain score without associated complications, confirming the effectiveness of the procedure.

Neuropathic pain may develop after neuronal injury and distinguishes itself from other painful conditions due to its unique clinical characteristics and for being refractory to treatment with conventional analgesics and non-steroidal anti-inflammatory drugs (NSAIDs). N-methyl-D-aspartate receptors (NMDARs) are known for their relation to neuroplasticity and play a role in neuropathic pain and opioid induced hyperalgesia. Ketamine is a N-methyl-D-aspartate (NMDA) antagonist with strong analgesic and anti-hyperalgesic properties and its addition to the treatment of neuropathic pain may reduce pain intensity in the short and long term and may improve overall quality of life. Therefore, a systematic review and meta-analysis were performed to investigate the addition of ketamine to the treatment of patients with neuropathic pain.Methods: Randomized controlled trials (RCTs) investigating the effect of ketamine on pre-defined outcomes including pain intensity at several time points, multidimensional pain scales, quality of life, mood, impact on interpersonal interaction, quality of sleep, impact on general daily activities, impact on work, and adverse outcomes, such as nausea and vomiting, and psychedelic effects were searched in the following databases: MEDLINE, CENTRAL, LILACS and EMBASE, from inception to April 2021. Reviewers independently screened potentially eligible articles, extracted data and assessed the risk of bias among eligible articles. We used the GRADE approach to rate the overall certainty of the evidence for each outcome.

Purpose: Ketamine is a N-methyl-D-aspartate (NMDA) antagonist with strong analgesic properties. Its addition to the treatment of neuropathic pain may reduce pain intensity and improve overall quality of life. A systematic review and meta-analysis of randomized controlled trials was performed to investigate the addition of ketamine to the treatment of patients with neuropathic pain. Patients and Methods: GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used to rate the overall certainty of the evidence for each outcome. Eighteen (18) randomized controlled trials including 706 participants were included for further analysis. Results: Ketamine addition to standard treatment of neuropathic pain (NP) resulted in a statistically significant reduction of pain intensity at one week after the end of treatment with ketamine (MD − 2.14, 95% CI − 2.65 to − 1.63; p< 0.00001) and after 30 days after the end of treatment with ketamine (MD − 1.68, 95% CI − 2.25 to − 1.12; p< 0.00001) and a statistically significant increase in discomfort (RR 4.06; 95% CI 1.18 to 13.95; p=0.03), and psychedelic effects (RR 4.94; 95% CI 2.76 to 8.84; p< 0.00001). Conclusion: There is a statistically significant pain reduction by adding ketamine to the treatment of chronic NP when compared to the standard treatment. However, such pain reduction comes at the expense of adverse outcomes, especially psychedelic effects related to the administration of ketamine. However, the overall quality of certainty of evidence is low due to the clinical heterogeneity among the intervention characteristics of the trials analyzed (different administration routes, dosing regimen, therapy durations, different clinical characteristics of the population investigated). Future large multi-centered trials are necessary to confirm or not the results of the present review.