Efeitos de dexmedetomidina em conjunto com o pré‐condicionamento isquêmico remoto em lesão de isquemia‐reperfusão renal em ratos

Background and objectivesThe aim of this study was to evaluate the effects of remote ischemic preconditioning by brief ischemia of unilateral hind limb when combined with dexmedetomidine on renal ischemia–reperfusion injury by histopathology and active caspase‐3 immunoreactivity in rats.Methods28 Wistar albino male rats were divided into 4 groups. Group I (Sham, n = 7): Laparotomy and renal pedicle dissection were performed at 65th minute of anesthesia and the rats were observed under anesthesia for 130 min. Group II (ischemia–reperfusion, n = 7): At 65th minute of anesthesia bilateral renal pedicles were clamped. After 60 min ischemia 24 h of reperfusion was performed. Group III (ischemia–reperfusion + dexmedetomidine, n = 7): At the fifth minute of reperfusion (100 μg/kg intra‐peritoneal) dexmedetomidine was administered with ischemia–reperfusion group. Reperfusion lasted 24 h. Group IV (ischemia–reperfusion + remote ischemic preconditioning + dexmedetomidine, n = 7): After laparotomy, three cycles of ischemic preconditioning (10 min ischemia and 10 min reperfusion) were applied to the left hind limb and after 5 min with group III.ResultsHistopathological injury scores and active caspase‐3 immunoreactivity were significantly lower in the Sham group compared to the other groups. Histopathological injury scores in groups III and IV were significantly lower than group II (p = 0.03 and p = 0.05). Active caspase‐3 immunoreactivity was significantly lower in the group IV than group II (p = 0.01) and there was no significant difference between group II and group III (p = 0.06).ConclusionsPharmacologic conditioning with dexmedetomidine and remote ischemic preconditioning when combined with dexmedetomidine significantly decreases renal ischemia–reperfusion injury histomorphologically. Combined use of two methods prevents apoptosis via active caspase‐3.     

Ultrassom de antro gástrico em gestantes a termo antes de cesariana eletiva

Background and objectivesPregnant women are considered patients at risk for pulmonary aspiration of gastric contents. The study aim was to evaluate the gastric antral cross‐sectional area using ultrasound.MethodIn this prospective study, 85 scheduled term pregnant women underwent gastric ultrasound. The outcomes were the measurement of the gastric antral cross‐sectional area (main outcome), the estimated gastric volume, the incidence of pregnant women at risk for pulmonary aspiration, and the association between gastric antral cross‐sectional area and clinical‐demographic characteristics. Gastric antral cross‐sectional area and gastric volume were compared according to body mass index < 30 or ≥ 30.ResultsThe median (IIQ) for gastric antral cross‐sectional area was 4 cm² (2.8‐6.3), for the estimated gastric volume it was 49.8 mL (33.7‐87.2), and for the gastric volume estimated in mL.kg^?1 it was 0.62 mL.kg^?1 (0.39‐0.95). The 95^th percentile [95% confidence interval (CI)] of the gastric antral cross‐sectional area and the estimated gastric volume were ≤ 10.3 cm² (95% CI: 7.6‐15.6) and 1.42 mL.kg^?1 (95% CI: 1.20‐2.64), respectively. The incidence of pregnant women at risk for pulmonary aspiration was 3.5% (CI: 3.5 (1.2‐9.8). There was a positive correlation between gastric antral cross‐sectional area and weight, p < 0.001 and body mass index < 0.001. Patients with a body mass index ≥ 30 had a gastric antral cross‐sectional area and an estimated gastric volume greater than those with a body mass index < 30, respectively, p < 0.01 and p < 0.02.ConclusionMeasuring the gastric antral cross‐sectional area of pregnant women is feasible and easy. There was positive correlation between gastric antral cross‐sectional area, body weight and body mass index. The estimation of gastric volume by measuring the gastric antral cross‐sectional area can identify patients at risk for pulmonary aspiration. Obese patients had a gastric antral cross‐sectional area and an estimated gastric volume greater than non‐obese patients.     

O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

Background

Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education.

Perda visual conversiva em pós‐operatório de cirurgia de coluna: relato de caso

Background and objective

Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder.

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.

Perfil de especialistas e de serviços em reumatologia pediátrica no estado de São Paulo

IntroductionPaediatric rheumatology (PR) is an emerging specialty, practised by a limited number of specialists. Currently, there is neither a record of the profile of rheumatology patients being treated in Brazil nor data on the training of qualified rheumatology professionals in the country.ObjectiveTo investigate the profile of PR specialists and services, as well as the characteristics of paediatric patients with rheumatic diseases, for estimating the current state of rheumatology in the state of São Paulo.Patients and methodsIn 2010, the scientific department of PR of the Paediatric Society of São Paulo administered a questionnaire that was answered by 24/31 accredited specialists in PR practising in state of São Paulo and by 8/21 institutions that provide PR care.ResultsMost (91%) of the surveyed professionals practise in public institutions. Private clinics (28.6%) and public institutions (37.5%) reported not having access to nailfold capillaroscopy, and 50% of the private clinics reported not having access to acupuncture. The average duration of professional practise in PR was 9.4 years, and 67% of the physicians had attended postgraduate programmes. Seven (87.5%) public institutions perform teaching activities, in which new paediatric rheumatologists are trained, and five (62.5%) offer postgraduate programmes. Two-thirds of the surveyed specialists use immunosuppressants and biological agents classified as “restricted use” by the Health Secretariat. The disease most frequently reported was juvenile idiopathic arthritis (29.1–34.5%), followed by juvenile systemic lupus erythematosus (JSLE) (11.6–12.3%) and rheumatic fever (9.1-15.9%). The incidence of vasculitis (including Henoch-Schönlein purpura, Wegener's granulomatosis, and Takayasu's arteritis) and autoinflammatory syndromes was higher in public institutions compared to other institutions (P = 0.03, P = 0.04, P = 0.002, and P < 0.0001, respectively). Patients with JSLE had the highest mortality rate (68% of deaths), mainly due to infection.ConclusionThe field of PR in the state of São Paulo has a significant number of specialists with postgraduate degrees who mostly practise at teaching institutions with infrastructures appropriate for the care of high-complexity patients.     

Alterações radiográficas de coluna cervical em artrite reumatoide

IntroductionThe involvement of the cervical spine is a common feature of rheumatoid arthritis (RA).ObjectiveTo study the prevalence of radiographic changes of the cervical spine in patients with RA and their association with clinical and serological profiles of the disease.MethodsWe analysed lateral (neutral position, hyperextension, hyperflexion) and transoral views of cervical spine radiographs from 80 individuals with RA to investigate the presence of atlanto-axial subluxation (AAS), basilar invagination (BI), and subaxial instability (SAI). Demographic, clinical (nodules, interstitial pneumonitis, secondary Sjögren's syndrome, medications etc.), and serologic (rheumatoid factor - RF, cyclic citrullinated peptide antibody – anti-CCP, and antinuclear factor - ANF) data were obtained from the clinical records.ResultsCervical spine misalignments were identified in 26/80 (32.5%) participants; AAS occurred in 12/80 (15%) participants, BI in 6/80 (7.5%), and SAI in 13/80 (32.5%). Odontoid erosions were identified in 16/80 (20.0%) participants. Cervical spine misalignment exhibited associations with age at onset and disease duration (P = 0.03 and 0.02, respectively). No associations were identified between the cervical spine changes and the participants’ ethnicity or gender, presence of nodules, interstitial pneumonitis, secondary Sjögren's syndrome, RF, ANF, or anti-CCP. The participants with cervical spine misalignment exhibited higher frequencies of odontoid erosion (P = 0.03).ConclusionsCervical spine misalignment was a common radiographic finding and occurred more frequently in participants with earlier onset and longer length of RA.     

Anestesia para parto cesáreo em paciente portadora de síndrome de Klippel‐Trenaunay

Introduction

Klippel‐Trenaunay syndrome is a rare congenital vascular disease characterized by cutaneous hemangiomas, varicosities, and limb asymmetry, which may evolve with coagulation disorders and hemorrhage as those more frequent complications in pregnant patients. Pregnancy is not advised in women with this syndrome due to increased obstetrical risk.

Adquirir habilidades no manejo de crises de hipertermia maligna: comparação de simulação de alta‐fidelidade versus estudo de caso em computador

Introduction

The primary purpose of this study was to compare the effect of high fidelity simulation versus a computer‐based case solving self‐study, in skills acquisition about malignant hyperthermia on first year anesthesiology residents.

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.     

Níveis plasmáticos de interleucina‐10 e óxido nítrico em resposta a duas taxas de fluxo em anestesia com desflurano

Objective

This study investigated interleukin‐10 and nitric oxide plasma levels following surgery to determine whether there is a correlation between these two variables and if different desflurane anesthesia flow rates influence nitric oxide and interleukin‐10 concentrations in circulation.

Materials and methods

Forty patients between 18 and 70 years and ASA I–II physical status who were scheduled to undergo thyroidectomy were enrolled in the study.

Interventions

Patients were allocated into two groups to receive two different desflurane anesthesia flow rates: high flow (Group HF) and low flow (Group LF).

Measurements

Blood samples were drawn at the beginning (t₀) and end (t₁) of the operation and after 24 h (t₂). Plasma interleukin‐10 and nitric oxide levels were measured using an enzyme‐linked‐immunosorbent assay and a Griess reagents kit, respectively. Hemodynamic and respiratory parameters were assessed.

Results

There was no statistically significant difference between the two groups with regard to interleukin‐10 levels at the times of measurement. Interleukin‐10 levels were increased equally in both groups at times t₁ and t₂ compared with preoperative concentrations. For both groups, nitric oxide circulating concentrations were significantly reduced at times t₁ and t₂ compared with preoperative concentrations. However, the nitric oxide value was lower for Group HF compared to Group LF at t₂. No correlation was found between the IL‐10 and nitric oxide levels.

Conclusion

Clinical usage of two different flow anesthesia forms with desflurane may increase interleukin‐10 levels both in Group HF and Group LF; nitric oxide levels circulating concentrations were significantly reduced at times t₁ and t₂ compared with preoperative concentrations; however, at 24 h postoperatively they were higher in Group LF compared to Group HF. No correlation was detected between interleukin‐10 and nitric oxide levels.     

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.     

Dexametasona perineural em bloqueio de plexo braquial interescalênico com levobupivacaína guiado por ultrassonografia para artroscopia de ombro em regime ambulatorial: ensaio clínico controlado e randomizado

Background and objectivesIn shoulder arthroscopy, on an outpatient basis, the patient needs a good control of the postoperative pain that can be achieved through regional blocks. Perineural dexamethasone may prolong the effect of these blocks. The aim of this study was to evaluate the effect of perineural dexamethasone on the prolongation of the sensory block in the postoperative period for arthroscopic shoulder surgery in outpatient setting.MethodsAfter approval by the Research Ethics Committee and informed consent, patients undergoing arthroscopic shoulder surgery under general anesthesia and ultrasound‐guided interscalene brachial plexus block were randomized into Group D – blockade performed with 30 mL of 0.5% levobupivacaine with vasoconstrictor and 6 mg (1.5 mL) of dexamethasone and Group C – 30 mL of 0.5% levobupivacaine with vasoconstrictor and 1.5 mL of 0.9% saline. The duration of the sensory block was evaluated in 4 postoperative moments (0, 4, 12 and 24 hours) as well as the need for rescue analgesia, nausea and vomiting incidence, and Visual Analog Pain Scale (VAS).ResultsSeventy‐four patients were recruited and 71 completed the study (Group C, n = 37; Group D, n = 34). Our findings showed a prolongation of the mean time of the sensitive blockade in Group D (1440 ± 0 min vs. 1267 ± 164 min, p < 0.001). It was observed that Group C had a higher mean pain score according to VAS (2.08 ± 1.72 vs. 0.02 ± 0.17, p < 0.001) and a greater number of patients (68.4% vs. 0%, p < 0.001) required rescue analgesia in the first 24 hours. The incidence of postoperative nausea and vomiting was not statistically significant.ConclusionPerineural dexamethasone significantly prolonged the sensory blockade promoted by levobupivacaine in interscalene brachial plexus block, reduced pain intensity and rescue analgesia needs in the postoperative period.     

Avaliação de entesopatia em pacientes com fibromialgia por meio do novo índice ultrassonográfico de entesite

ObjectiveThe aim of the present study is to determine the frequency of enthesopathy in fibromyalgia (FM) by using a newly developed ultrasonography (US) method, the Madrid Sonography Enthesitis Index (MASEI).MethodsThis study was conducted on 38 consecutive patients with FM and 48 healthy sex- and age-matched controls. Six entheseal sites (olecranon tuberosity, superior and inferior poles of patella, tibial tuberosity, superior and inferior poles of calcaneus) on both lower limbs were evaluated. All US findings were identified according to MASEI. Scores of patients and controls were compared by Student's t-test and Mann-Whitney U-test. Validity was analysed by receiver operating characteristic curve. Values of P < 0.05 were considered significant.ResultsTotal enthesitis score was 7.39 ± 4.99 (mean ± SD) among FM patients and 3.7 ± 3.22 among healthy controls (P < 0.001). The receiver operating characteristic curve established an ultrasound score of > 3.5 in the FM group as the best cut-off point to differentiate between cases and controls. No statistically significant correlation was found between the MASEI score and the FM disease duration, and the location of the tender points.ConclusionsMisdiagnoses of FM are harmful to patients and the community, and the presence of enthesopathy among FM patients increases. Its detection with the MASEI score may help to discriminate FM patients presenting with ill-defined symptoms and signs, in order to prevent mistreatment.     

Eficácia de diferentes doses e esquemas de administração de ácido tranexâmico em cirurgias ortopédicas de grande porte: estudo randomizado

BackgroundTranexamic acid was studied in four different dosage regimens and their efficacy was compared for perioperative blood loss reduction, blood transfusion requirements and deep vein thrombosis (DVT) complication.MethodsTwo hundred patients undergoing major orthopedic procedures were divided into five groups containing 40 each: placebo, low dose (bolus 10 mg.kg^‐1), low dose + maintenance (bolus 10 mg.kg^‐1 + maintenance 1 mg.kg^‐1.hr^‐1), high dose (bolus 30 mg.kg^‐1) and high dose + maintenance (bolus 30 mg.kg^‐1 + maintenance 3 mg.kg^‐1.hr^‐1). Surgical blood loss was measured intraoperatively and drains collection in the first 24 hours postoperative period. Blood transfusion was done when hematocrit falls less than 25%. DVT screening was done in the postoperative period.ResultsThe intraoperative blood loss was 440 ± 207.54 mL in the placebo group, 412.5 ± 208.21 mL in the low dose group, 290 ± 149.6 ml in the low dose plus maintenance group, 332.5 ± 162.33 mL in the high dose group and 240.7 ± 88.15 mL in the high dose maintenance group (p < 0.001). The reduction in postoperative blood loss in the drain for the first 24 hours was 80 ± 44.44 mL in the placebo group, 89.88 ± 44.87 mL in the low dose group, 56.7 ± 29.12 mL in the low dose plus maintenance group, 77.9 ± 35.74 mL in the high dose group and 46.7 ± 19.9 mL in the high dose maintenance group (p < 0.001). DVT was not encountered in any patient.ConclusionTranexamic acid was most effective in reducing surgical blood loss and blood transfusion requirements in a low dose + maintenance group.     

Reflexo de Bezold‐Jarisch em paciente submetida à simpatectomia endoscópica para tratamento de angina pectoris refratária: relato de caso

Background and objectives

Ischemic cardiomyopathy is characterized by imbalance between supply and demand of myocardial oxygen. Endoscopic transthoracic sympathectomy is a therapeutic option indicated in refractory cases. However, the patient's position on the operating table may favor ischemic coronary events triggering the Bezold‐Jarisch reflex.

Considerações anestésicas para craniotomia em paciente acordado: relato de caso

Background and objectives

The conscious patient cooperation during neurological procedures has become necessary for the delimitation of areas to be managed by a neurosurgeon, with better results in the treatment of tumor lesions, vascular or epileptic foci, and lesser sequelae. The need for perioperative awareness (responsiveness to commands) challenges anesthesiologists to further ensure patient safety during the procedure. Several techniques have been described for this purpose.

Efeito do bloqueio paravertebral torácico na redução de seroma em cirurgia de mama – estudo randomizado controlado

BackgroundIncreasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.ObjectiveWith this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.MethodsForty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient‐controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24^th hour postoperatively.Results and conclusionsMean seroma formation at postoperative 24^th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24^th hour but mean morphine consumption at postoperative 24^th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.     

Reação atípica à anestesia em distrofia muscular de Duchenne/Becker

Background and objectives

Duchenne/Becker muscular dystrophy affects skeletal muscles and leads to progressive muscle weakness and risk of atypical anesthetic reactions following exposure to succinylcholine or halogenated agents. The aim of this report is to describe the investigation and diagnosis of a patient with Becker muscular dystrophy and review the care required in anesthesia.