Sedação com dexmedetomidina e remifentanil em anestesia local para monitoração intraoperatória da fala: um relato de caso

Background and objective

Some surgical procedures such as laryngoplasty require patients to remain conscious during the intraoperative phase in order to enable speech monitoring. Dexmedetomidine and remifentanil were used in this study, since they promote appropriate patient collaboration with facilitated awakening, and are rapidly eliminated.

O ultrassom substituirá o estetoscópio?: relato de caso sobre ventilação monopulmonar neonatal

Background and objectivesOne‐lung ventilation and selective intubation in neonates can be challenging due to intrinsic physiological specificities and material available. Ultrasound (US) is being increasingly used in many extents of anaesthesiology including confirmation of endotracheal tube position.Case reportWe present a case report of a neonate proposed for pulmonary lobectomy by thoracoscopy in which lung exclusion was confirmed by ultrasound.ConclusionUS is a rapid, more sensitive and specific method than auscultation to evaluate tracheal intubation and lung exclusion.     

Manutenção da anestesia inalatória com a máscara facial Janus para substituição de válvula aórtica transcateter: uma série de casos

Background and objectives

Aortic stenosis is the most common type of heart valve disease. Percutaneous aortic valve replacement has become the alternative for patients considered at high risk for surgery. Controlled mechanical ventilation with tracheal intubation has been the choice for this type of procedure, however the use of noninvasive ventilation in cardiac patients has shown to be beneficial. Janus is a novel full‐face mask that allows application of noninvasive ventilation support during anesthesia. Our main objective was to evaluate the feasibility of transcatheter aortic valve replacement with prolonged transesophageal echocardiographic monitoring under deep inhalational sedation delivered through a new mask for noninvasive ventilation.

Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina – relato de caso

Introduction

Advanced hepatic disease may – in addition to the widely recognized hemorrhagic complications – occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM^®).

Cetamina como adjuvante de bupivacaína em bloqueio do nervo infraorbitário para analgesia após correção de lábio leporino

Objectives

We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra‐oral infra‐orbital nerve block in children undergoing cleft lip surgeries.

Correção endovascular de lesão de artéria subclávia secundária à cateterismo de veia jugular interna: relato de caso

Background and objectivesUltrasound‐guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life‐threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.Case reportWe describe a case of the successful endovascular repair of right subclavian artery injury in a 75‐year‐old woman. Subclavian artery was injured secondary to ultrasound‐guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.ConclusionUnder general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.     

Insuficiência hepática fulminante após transplante simultâneo de rim‐pâncreas: um relato de caso

We describe an unusual case of hyperacute hepatic failure following general anesthesia in a patient receiving a simultaneous kidney‐pancreas transplant. Despite an aggressive evaluation of structural, immunological, viral, and toxicological causes, a definitive cause could not be elucidated. The patient required a liver transplant and suffered a protracted hospital course. We discuss the potential causes of fulminant hepatic failure and the perioperative anesthesia management of her subsequent liver transplantation.     

Conduta em obstrução por coágulo em cânula de duplo lúmen bicaval após diagnóstico guiado por ETE: relato de caso

BackgroundVeno‐venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno‐venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot‐obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography.Case reportA 39 year‐old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno‐venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus‐like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later.DiscussionThe diagnosis of veno‐venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno‐venous extracorporeal membrane oxygenation.     

Comportamento da variação do volume sistólico em pacientes hemodinamicamente estáveis durante cirurgia torácica com períodos de ventilação monopulmonar

Introduction

In last few years, emphasis was placed in goal‐directed therapy in order to optimize patient's hemodynamic status and improve their prognosis. Parameters based on the interaction between heart and lungs have been questioned in situations like low tidal volume and open chest surgery. The goal of the study was to analyze the changes that one‐lung ventilation can produce over stroke volume variation and to assess the possible impact of airway pressures and lung compliance over stroke volume variation.

Tamponamento cardíaco: uma complicação rara da cateterização venosa central – relato de um caso clínico

The extensive use of central venous catheters (CVC) in a hospital environment leads to increased iatrogenic complications, as more catheters are used enclosed and its maintenance is prolonged. Several complications are known to be related to central venous catheter, of which the uncommon cardiac tamponade (CT), hardly recognized and associated with high mortality.We present a clinical case, with favorable outcome, of a patient who developed a CT 17 days after CVC placement, and try to reflect on the measures that can be taken to reduce its incidence, as well as the therapeutic approaches to practice in the presence of a suspected CT.     

Amaurose e paralisia do III e do VI pares cranianos contralaterais após bloqueio peribulbar – relato de caso

Background and objectives

Peribulbar anesthesia has emerged as a safer option compared with intraconal retrobulbar block. Still, peribulbar anesthesia may not be considered without risk. Numerous complications have been described when performing this technique. This report aims to describe a rare case of amaurosis and contralateral paralysis while attempting to perform a peribulbar anesthesia.

Antinocicepção intravenosa sem opioides orientada pelo Índice de Analgesia/Nocicepção: relato de caso

BackgroundOpioid‐free anesthesia decreases the incidence of opioid adverse events, but its optimal antinociceptive depth has not been clearly defined. Personalizing intraoperative opioid‐free infusions with a nociception monitor may be the solution.Case reportWe describe the feasibility and potential limitations of titrating opioid‐free antinociception during major abdominal surgery using the Analgesia Nociception Index (Mdoloris, Lille, France) in an obese patient. After stabilizing the patient's nociception‐antinociception balance intraoperatively we quickly reversed anesthesia and the patient did not require postoperative opioids.ConclusionPersonalizing opioid‐free antinociception with a nociception monitor is feasible. It may optimize intraoperative antinociception and improve postoperative comfort.     

Associação entre artrite idiopática juvenil e osteogenesis imperfecta – relato de caso

The authors report a rare association case of juvenile idiopathic arthritis (JIA) and osteo- genesis imperfecta (OI) in a 53 years-old female patient, present a literature review and dis- cuss the radiological aspects of the temporo-mandibular joint involvement. To our knowl- edge, this is the first case report of JIA an OI association.     

Anestesia para cesárea em gestante com síndrome de Cockayne: relato de caso

Cockayne syndrome is an autosomal recessive multi‐systemic disorder due to DNA repair failure. It was originally described in 1936 in children of small stature, retinal atrophy and deafness, characterized by dwarfism, cachexia, photosensitivity, premature aging and neurologic deficits. The most typical feature is described as birdlike facies: protruding maxilla, facial lipoatrophy, sunken eyes, large ears and thin nose. Difficult airway management with subglottic stenosis and risk of gastric content aspiration has been described. Although the clinical characteristics of Cockayne syndrome have been well described in pediatric publications, there is only one report in the literature on anesthesia for an obstetric patient. We report the case of a pregnant patient diagnosed with Cockayne syndrome, submitted successfully to spinal anesthesia for a cesarean section due to cephalopelvic disproportion. In view of the difficult decision between inducing general anesthesia in a patient with a likely difficult airway, or neuraxial anesthesia in a patient with cardiovascular, respiratory and neurocognitive limitations, we suggest tailored management to reach the best results for the mother and newborn.     

Paralisia de cordas vocais após intubação endotraqueal: uma complicação incomum da anestesia geral

Background

General anesthesia is a safe, frequent procedure in clinical practice. Although it is very unusual in procedures not related to head and or neck surgery, vocal cord paralysis is a serious and important complication. Incidence has been associated with patient age and comorbidities, as well as the position of the endotracheal tube and cuff. It can become a dangerous scenario because it predisposes aspiration.

Bloqueio contínuo do plano do eretor da espinha lombar para o controle da dor pós‐operatória em procedimento de revisão de cirurgia do quadril: relato de caso

The number of total hip arthroplasty cases performed each year continues to increase; accordingly, so does the number of revision total hip arthroplasty procedures. While our traditional method of analgesia for these patients has involved multimodal medications and a continuous lumbar plexus block, we report two cases of patients who received continuous lumbar erector spinae plane blocks. Both patients exhibited excellent pain control postoperatively and were able to discharge home on postoperative day one. This case report illustrates the possible utility of continuous erector spinae plane blocks for postoperative analgesia in the more frequently occurring revision total hip arthroplasty surgeries.     

Valor preditivo das citocinas plasmáticas para lesão renal aguda após cirurgia de ressecção pulmonar: estudo observacional prospectivo

Background and objectivesPatients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury.MethodsWe prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra‐operative periods of one‐lung ventilation. Fiberoptic broncho‐alveolar lavage was performed in each lung before and after one‐lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48 h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re‐admission, and short‐term and long‐term mortality.ResultsThe incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin‐6 at 6 h was the most predictive cytokine of acute kidney injury (cut‐off point at 4.89 pg.mL^?1).ConclusionsIncreased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin‐6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.     

Tomografia por emissão de pósitrons com FDG‐18F na avaliação de pacientes com artrite reumatoide – revisão sistemática

IntroductionRheumatoid arthritis (RA) is a disease characterized by inflammation of the synovial membrane. Several authors have investigated the role of positron emission tomography (PET) with fluorine‐18 fluorodeoxyglucose (¹⁸F‐FDG) in RA.ObjectivesTo systematically review the current literature on the role of ¹⁸F‐FDG PET in the diagnosis, determination of disease activity and assessment of treatment response in patients with RA.MethodsSearches were conducted in Medline, Cochrane Library, Lilacs, Pubmed and Scopus in Portuguese, English and Spanish languages, using the keywords «rheumatoid arthritis», «synovitis», «FDG», «PET», «glycolytic metabolism» and «disease activity».Results142o articles were initially identified, of which only 40 were related directly to the subject. Twelve original articles and three case reports that met the inclusion criteria were selected.DiscussionThe presence of activated macrophages and fibroblasts in pannus are responsible for the intense periarticular uptake of ¹⁸F‐FDG. The uptake patterns do not allow the differential diagnosis with other arthritides. The uptake intensity and the number of joints involved are metabolic parameters of disease activity that correlate well with the composite indices. Longitudinal studies of PET have proven useful in assessing the response to treatment with anti‐TNF. When performed early, PET can predict the therapeutic response.ConclusionAlthough the actual role of this new technique for the investigation of RA is not yet established, ¹⁸F‐FDG PET is a promising tool in determining the activity and prediction of response to treatment of patients with RA.     

Comparação entre ventilação garantida por volume controlado por pressão e ventilação controlada por volume em pacientes obesos durante cirurgia laparoscópica ginecológica na posição de Trendelenburg

Background and objectivesThe aim of this study was to investigate the efficacy of the pressure‐controlled, volume‐guaranteed (PCV‐VG) and volume‐controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position.MethodsPatients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40 kg.m^-2 were randomized to receive either VCV or PCV‐VG ventilation. The tidal volume was set at 8 mL.kg^-1, with an inspired oxygen concentration of 0.4 with a Positive End‐Expiratory Pressure (PEEP) of 5 mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO₂, arterial blood gas analysis, heart rate and mean arterial pressure at 5 minutes after induction of anesthesia in the and at 5, 30 and 60 minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded.ResultsThe PCV‐VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO₂ levels were significantly higher in the PCV‐VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position.ConclusionsThe PCV‐VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV‐VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.     

Bloqueio paravertebral torácico guiado por ultrassom para correção de ileostomia em alça em DPOC grave: um relato de caso

Background and objectives

Ultrasound‐guided thoracic paravertebral block is usually considered a good alternative to epidural thoracic for anesthesia and pain control in thoracic and breast surgery. Furthermore it has also been used during abdominal surgery lately, especially hepatic and renal surgery. However, its role is poorly defined in this context. The purpose of this report was to highlight the role of thoracic paravertebral block in providing effective anesthesia and analgesia during both the abdominal surgical intervention and pain control in post‐operative period, avoiding possible complications which general anesthesia may arise, which are fairly common in patients with chronic obstructive pulmonary disease and similar comorbidities.