Avaliação da analgesia com o uso da mistura eutética de anestésico local (lidocaína e prilocaína) e/ou analgesia inalatória com óxido nitroso a 50% em oxigênio (Livopan®) em pacientes pediátricos submetidos ao procedimento de punção lombar para quimioterapia

Abstract

Objective: to comparing the analgesic effect of nitrous oxide at 50% oxygen (Livopan®) and the eutectic mixture of local anesthetic lidocaine and prilocaine (EMLA®) and synergism between the operations before, during and after lumbar puncture for chemotherapy in pediatric patients hematology. Methods: randomized, controlled triple blinding. We studied 52 patients in the treatment of acute leukemia (myeloid and lymphoid) or non-Hodgkin lymphoma, aged four to 16 years and clinical indication for lumbar puncture for chemotherapy. The study was conducted in three centers of Hematology (Hospital das Clínicas, Hospital Emygdio Germano - Santa Casa de Belo Horizonte and Benjamin Guimarães Foundation - Whale Hospital) from May 2009 to August 2011. Patients were randomized into three treatment groups using a random number table: group 1: EMLA® associated with Livopan® (n=16), group 2: EMLA® associated with O2 (placebo of Livopan®) (n=19) and group 3: Livopan® associated with placebo cream EMLA® (n=17). Pain-related response to lumbar puncture was evaluated using the Wong Baker faces scale and the visual numeric scale and six distinct stages of the procedure were considered. Hemodynamic and respiratory parameters like heart rate, blood oxygen saturation and mean arterial pressure were also evaluated. Results: there was a statistically significant difference between the three groups (p = 0.0001), whereas the median pain scores during the first attempt at lumbar puncture. Group 2 had the highest pain score (median 4.00) while groups 1 and 3 had the lowest scores (median 0.00). There was no statistically significant difference between the study groups in relation to hemodynamic and respiratory parameters in any of the evaluation period, except for mean arterial pressure (p = 0.002) after three minutes of interruption of gas. When a second attempt to puncture was necessary, there was a difference between pain scores only between groups 1 and 2 (p = 0.013) but not between groups 1 and 3 or 2 and 3 (p> 0.05). Adverse effects related to the use of the interventions studied were considered mild and transient, including an episode of vomiting, and between patients using five Livopan® euphoria and three had had some degree of dissociation (dreams). Conclusions: the use of EMLA® associated to Livopan® or Livopan® alone showed to be a better choice considering their efficacy of pain control for lumbar puncture in children with cancer than the isolated use of EMLA® cream. The synergic effect of the drugs could be shown mainly when a second attempt to successful puncture was necessary justifying the use of EMLA® associated to Livopan®. The safety profile of Livopan® is also an interesting point that makes the analgesia and sedation for lumbar puncture feasible in the ambulatory set without the separation of the children from the parents, the necessity of fasting and also less expensive than procedures in the operating room.