Sialometria: Aspectos de interesse clínico

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mu- cus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration.Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glan- dular parenchyma by infectious processes, granulomatous diseases or autoimmune and in- flammatory conditions (such as Sjögren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evalua- tion of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequenc- es of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.     

Síndrome urofacial de ochoa: caso clínico

An 11 year-old girl had an urinary diversión because of a complex uropathy with vesical sphincter dyssinergism. Her inexpressive face with lost eyes and forced gestures, especially when smiling –her smile looking rather like weeping- was the clue to the diagnosis of Ochoa’s syndromeShe underwent psoic bladder fixation, right ureteral reimplantation, bladder neck losening and cystostomy undiversion. At follow-up, renal function deteriorated. She has recently received a kidney transplantation in another institution, and is now symptom-free     

Analgesia neuraxial em uma parturiente com síndrome de Vacterl em trabalho de parto normal

Introduction

The term VACTERL is an acronym for an association of congenital malformations: including vertebral, anal, cardiac, tracheo‐esophageal, renal and limb anomalies. VACTERL anomalies pose a formidable challenge to anesthesiologists. We describe the anesthetic management of a parturient with VACTERL association, who underwent neuraxial analgesia for labor and vaginal delivery.

Bloqueio perioperatório do plexo lombar e isquemia cardíaca em pacientes com fratura de quadril: ensaio clínico randomizado

Background

Perioperative myocardial ischemia is common among patients undergoing hip fracture surgery. Our aim is to evaluate the efficacy of perioperative continuous lumbar plexus block in reducing the risk of cardiac ischemic events of elderly patients undergoing surgery for hip fractures, expressed as a reduction of ischemic events per subject.

Bloqueo BRILMA para extirpación de cartílago costal: caso clínico

The block of the lateral branches of the intercostal nerves in the middle axillary line (BRILMA) is an interfascial ultrasound-guided block for analgesia in thoracic wall and upper abdominal surgery, presenting as an adequate alternative to neuraxial techniques. We present the case of a 49-year-old female scheduled for idiopathic subglottic stenosis repair with a costal cartilage graft from the 10^th rib and tracheotomy. At the end of the surgery, unilateral ultrasound-guided BRILMA block with 20 ml of ropivacaine 0.2% was performed at the level of the 6^th rib, uneventfully. Postoperatively, the patient referred a maximum level of pain of 3/10. There was no opioid consumption after the 2^nd postoperative day, although a subcostal incision may produce considerable pain. BRILMA is a superficial block, easily reproducible in most patients. It diminishes the number of punctures needed in the thoracic wall, as well as the risk for pneumothorax and local anesthetic toxicity.     

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.

Uso de sugamadex pelo peso corporal ideal versus corrigido em 20% e 40% em cirurgia bariátrica – ensaio clínico randômico e duplo‐cego

Background and objectives

The weight parameters for use of sugammadex in morbidly obese patients still need to be defined.

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.     

Vía aérea difícil en paciente con linfoma. Descripción de un caso clínico

A 86-year-old male patient, diagnosed with lymphoma, was scheduled for a submaxillectomy to choose his best chemotherapy treatment. He referred recent voice changes and laterocervical adenopathies without respiratory symptoms. There were no additional risk predictors in preoperative airway assessment. Following anaesthesic induction, an upper airway obstruction occurred. After that, an unexpected difficult airway was encountered. Both clinical situations resulted in unpredicted difficult airway management. Image tests seen after the procedure revealed a severe narrowing of parapharyngeal space due to Waldeyer's ring hypertrophy. This medical condition had remained unnoticed in preoperative assessment.Advanced lymphoproliferative syndromes cause disseminated adenopathies whose parapharyngeal involvement can lead to a difficult airway even in the absence of preoperative risk predictors.     

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.

Intubação traqueal difícil com fibra óptica em bebê de um mês de idade com síndrome de Treacher Collins

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al.

Recomendaciones sobre el uso de las instilaciones endovesicales de ácido hialurónico en el síndrome de dolor vesical

IntroductionBladder pain syndrome (BPS) is a complex syndrome, without a clearly defined etiology that encompasses different entities, such as interstitial cystitis. This leads to difficulties in establishing a precise definition, obtaining accurate prevalence data, and defining diagnostic criteria and standardized assessment methods. Moreover, there is no consensus regarding the treatment of BPS. Intravesical instillations with hyaluronic acid (HA) are an option, although no specific recommendations have been made yet.ObjectiveTo synthesize the scientific evidence on the therapeutic options available for BPS and to establish a work plan and recommendations for the use of intravesical instillations with HA.The Spanish Association of Urology, through the Functional, Female, and Urodynamic Urology Group, created a commission of experts. This commission was in charge of reviewing literature (evidence), agreeing on the work plan, and proposing recommendations.ResultsThere is great variability in literature on the treatment of BPS, without a standard regimen of intravesical instillation with HA (frequency and duration of initial and maintenance treatment).ConclusionsIntravesical HA instillations (usual dose of 40 mg) are effective and safe. They can be combined with other options, with efficacy still to be determined in some cases. Treatment is divided into several initial weekly sessions, followed by maintenance treatment, usually monthly (unestablished duration of cycles).Recommendations on the management of BPS were agreed, with diagnostic criteria and guidelines for treatment with intravesical HA (initiation, reassessment, and follow-up).     

Estado actual de la cirugía transumbilical por puerto único en urología: retos y aplicaciones

ContextLaparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology.Acquisition of evidenceA nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described.Synthesis of evidenceLESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach.ConclusionsAlthough the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.     

Consenso sobre el impacto clínico de la nueva evidencia científica disponible sobre hiperplasia benigna prostática

ObjectivesTo study the technical opinion of an expert panel and reach a consensus of professional criterion in relation to the most recent scientific evidence in Benign Prostatic Hyperplasia (BPH) in the scopes of diagnosis, progression criteria, medical treatment and surgical treatment.Material and methodsSystematized review of the literature of the last 10 years in BPH by means of a scientific committee and elaboration of a 64-question questionnaire divided into three strategic areas: 1.- Diagnosis and stratification of the patients with BPH considering the progression risk factors. 2.-Novelties in the medical treatment and 3.- New contributions in the surgical and minimally invasive treatment in BPH. A panel of 50 urologists standing out for their knowledge in BPH distributed throughout the national geographic area was chosen, establishing the Delphi methodology for the study through the application of two successive online surveys.ResultsThe 50 experts consulted completed the two groups of the questionnaire. In the first, a consensus of criterion was observed in 50 out of the 64 questions analyzed, achieving a consensus in 59/65 (92.5%) in the second round, which included aspects of morbidity of the lower urinary tract symptoms (LUTS), diagnostic tests necessary in the initial evaluation of the specialist, stratification of the patients in relation to the risk of progression, strategies of step-by-step medical therapy and combination in patients with risk of Acute Urinary Retention (AUR) or surgery and of the indications of surgical therapy and the role of new less invasive treatments.ConclusionsIn a condition of the high prevalence of BPH, in which we have seen important changes in its entire spectrum in recent years, the obtaining of an elevated consensus to which a large number of reference specialists in this condition have contributed will be of great importance for the usual clinical management of this disease.     

Trombose de seios durais após analgesia peridural para parto: caso clínico

Background and objectives

Neurological complications of spinal anesthesia are rare conditions. Headache caused by low pressure of the cerebrospinal fluid is one of the most frequent, which occurs after post‐dural puncture. A comprehensive history and physical exam must be carried out before making the diagnosis of Post‐Dural Puncture Headache (PDPH) and additional tests are necessary to exclude the possibility of developing serious neurological complications such as Dural Sinus Thrombosis (DST). According to the Case Report a differential diagnosis between Dural Sinus Thrombosis with PDPH is discussed.

Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior

Background and objectives

Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first‐line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block.

Hernia vesical inguinoescrotal gigante. caso clínico y revisión de la literatura

Bladder hernia is an uncommon condition with a frequency between 0,5 and 3%, reaching the 10% between patients older than 50 years. It´s more predominant in males aged between 50 and 70. The diagnosis usually happens in the course of surgical repair of inguinal hernias, because the bladder hernia has no specific clinical findings. Management includes the resection or reduction of the bladder hernia, with de-obstruction of the lower urinary tract, if present, and repairmen of inguinal path. We report a new case and review the literature     

Efeito da pré‐administração de flurbiprofeno axetil na CE50 do propofol durante anestesia em pacientes não estimulados: estudo clínico randomizado

Background and objectivesPreoperative use of flurbiprofen axetil (FA) is extensively adopted to modulate the effects of analgesia. However, the relationship between FA and sedation agents remains unclear. In this study, we aimed to investigate the effects of different doses of FA on the median Effective Concentration (EC50) of propofol.MethodsNinety‐six patients (ASA I or II, aged 18–65 years) were randomly assigned into one of four groups in a 1:1:1:1 ratio. Group A (control group) received 10 mL of Intralipid, and groups B, C and D received 0.5 mg.kg^‐1, 0.75 mg.kg^‐1 and 1 mg.kg^‐1 of FA, respectively, 10 minutes before induction. The depth of anesthesia was measured by the Bispectral Index (BIS). The “up‐and‐down” method was used to calculate the EC50 of propofol. During the equilibration period, if BIS ≤ 50 (or BIS > 50), the next patient would receive a 0.5 μg.mL^‐1‐lower (or‐higher) propofol Target‐Controlled Infusion (TCI) concentration. The hemodynamic data were recorded at baseline, 10 minutes after FA administration, after induction, after intubation, and 15 minutes after intubation.ResultsThe EC50 of propofol was lower in Group C (2.32 μg.mL^‐1, 95% Confidence Interval [95% CI] 1.85–2.75) and D (2.39 μg.mL^‐1, 95% CI 1.91–2.67) than in Group A (2.96 μg.mL^‐1, 95% CI 2.55–3.33) (p = 0.023, p = 0.048, respectively). There were no significant differences in the EC50 between Group B (2.53 μg.mL^‐1, 95% CI 2.33–2.71) and Group A (p ˃ 0.05). There were no significant differences in Heart Rate (HR) among groups A, B and C. The HR was significantly lower in Group D than in Group A after intubation (66 ± 6 vs. 80 ± 10 bpm, p < 0.01) and 15 minutes after intubation (61 ± 4 vs. 70 ± 8 bpm, p < 0.01). There were no significant differences among the four groups in Mean Arterial Pressure (MAP) at any time point. The MAP of the four groups was significantly lower after induction, after intubation, and 15 minutes after intubation than at baseline (p < 0.05).ConclusionHigh‐dose FA (0.75 mg.kg^‐1 or 1 mg.kg^‐1) reduces the EC50 of propofol, and 1 mg.kg^‐1 FA reduces the HR for adequate anesthesia in unstimulated patients. Although this result should be investigated in cases of surgical stimulation, we suggest that FA pre‐administration may reduce the propofol requirement when the depth of anesthesia is measured by BIS.     

Mastectomía libre de opioides bajo anestesia-analgesia epidural torácica en un paciente con estenosis traqueal crítica: caso clínico

Mastectomy is traditionally performed under general anaesthesia and invasive ventilation, and is often complemented with regional techniques. In this setting, tracheal stenosis can pose a challenge to airway management. The aim of this report is to describe the successful management of a 68-year-old woman with severe subglottic tracheal stenosis undergoing mastectomy due to breast cancer. Surgery was performed without airway instrumentation under an opioid-free regimen consisting of thoracic epidural, propofol and dexmedetomidine perfusion, and non-opioid analgesics. Spontaneous ventilation and adequate perioperative analgesia were achieved. Opioid-free anaesthesia without airway instrumentation, consisting of thoracic epidural anaesthesia and sedation, is a good alternative in patients undergoing mastectomy in whom airway manipulation is best avoided.     

Dose baixa de propofol versus lidocaína para alívio de laringoespasmo resistente pós‐extubação em paciente obstétrica

Background

Post‐extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5 mg.kg^?1) vs. lidocaine (1.5 mg.kg^?1) for treatment of resistant post‐extubation laryngospasm in the obstetric patients, after failure of the standard measures.