Bloqueio dos nervos ílio‐hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós‐operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom

Objectives

The purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy.

Methods

40 patients, ASA I–II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20 ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24 h postoperatively.

Results

VAS scores at rest in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p < 0.01 or p < 0.001). VAS scores at movement in the recovery room and all the clinical follow‐up points were found significantly less in Group ultrasound (p < 0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p < 0.05, p < 0.001, p < 0.001 respectively).

Conclusion

According to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block‐related complications.     

Atividade simpática de cetamina S‐(+) em doses baixas no espaço epidural

Background and objectives

S‐(+)‐ketamine is an intravenous anaesthetic and sympathomimetic with properties of local anaesthetic. It has an effect of an analgetic and local anaesthetic when administered epidurally, but there are no data whether low doses of S‐(+)‐ketamine have sympathomimetic effects. The aim of this study was to determine whether low doses of S‐(+)‐ketamine, given epidurally together with local anaesthetic, have any effect on sympathetic nervous system, both systemic and below the level of anaesthetic block.

Methods

The study was conducted on two groups of patients to whom epidural anaesthesia was administered to. Local anaesthesia (0.5% bupivacaine) was given to one group (control group) while local anaesthesia and S‐(+)‐ketamine were given to other group. Age, height, weight, systolic, diastolic and mean arterial blood pressure were measured. Non‐competitive enzyme immunochemistry method (Cat Combi ELISA) was used to determine the concentrations of catecholamines (adrenaline and noradrenaline). Immunoenzymometric determination with luminescent substrate on a machine called Vitros Eci was used to determine the concentration of cortisol. Pulse transit time was measured using photoplethysmography. Mann–Whitney U‐test, Wilcoxon test and Friedman ANOVA were the statistical tests. Blood pressure, pulse, adrenaline, noradrenaline and cortisol concentrations were measured in order to estimate systemic sympathetic effects.

Results

40 patients in the control group were given 0.5% bupivacaine and 40 patients in the test group were given 0.5% bupivacaine with S‐(+)‐ketamine. Value p < 0.05 has been taken as a limit of statistical significance.

Conclusions

Low dose of S‐(+)‐ketamine administered epidurally had no sympathomimetic effects; it did not change blood pressure, pulse, serum hormones or pulse transit time. Low dose of S‐(+)‐ketamine administered epidurally did not deepen sympathetic block. Adding 25 mg of S‐(+)‐ketamine to 0.5% bupivacaine does not deprive sympathetic tonus below the level of epidural block at the moment of most expressed sympathetic block and has no effect on sympathetic tonus above the block level.     

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.     

Estudo randômico e duplo‐cego de profilaxia com fibrinogênio para reduzir o sangramento em cirurgia cardíaca

Background and objectives

Postoperative bleeding has a great clinical importance and can contribute to increased mortality and morbidity in patients undergoing coronary artery bypass graft surgery. In this prospective, randomized, double‐blind study, we evaluated the effect of prophylactic administration of fibrinogen concentrate on post‐coronary artery bypass graft surgery bleeding.

Methods

A total of 60 patients undergoing coronary artery bypass surgery were randomly divided into two groups. Patients in the fibrinogen group received 1 g of fibrinogen concentrate 30 min prior to the operation, while patients in the control group received placebo. Post‐operative bleeding volumes, prothrombin time, partial thromboplastin time, INR, hemoglobin and transfused blood products in both groups were recorded. A strict red blood cell transfusion protocol was used in all patients.

Results

There were no significant differences between intra‐operative packed red blood cells infusion in the studied groups (1.0 ± 1.4 in fibrinogen group, and 1.3 ± 1.1 in control group). Less postoperative bleeding was observed in the fibrinogen group (477 ± 143 versus 703 ± 179, p = 0.0001). Fifteen patients in the fibrinogen group and 21 in the control group required post‐op packed red blood cells infusion (p = 0.094). No thrombotic event was observed through 72 h after surgery.

Conclusion

Prophylactic fibrinogen reduces post‐operative bleeding in patients undergoing coronary artery bypass graft.     

O valor preditivo do peptídeo natriurético tipo‐B em resultados de crianças com hipertensão pulmonar submetidas à cirurgia cardíaca congênita

Background and objectives

In children undergoing congenital heart surgery, plasma brain natriuretic peptide levels may have a role in development of low cardiac output syndrome that is defined as a combination of clinical findings and interventions to augment cardiac output in children with pulmonary hypertension.

Methods

In a prospective observational study, fifty‐one children undergoing congenital heart surgery with preoperative echocardiographic study showing pulmonary hypertension were enrolled. The plasma brain natriuretic peptide levels were collected before operation, 12, 24 and 48 h after operation. The patients enrolled into the study were divided into two groups depending on: (1) Development of LCOS which is defined as a combination of clinical findings or interventions to augment cardiac output postoperatively; (2) Determination of preoperative brain natriuretic peptide cut‐off value by receiver operating curve analysis for low cardiac output syndrome. The secondary end points were: (1) duration of mechanical ventilation ≥72 h, (2) intensive care unit stay >7days, and (3) mortality.

Results

The differences in preoperative and postoperative brain natriuretic peptide levels of patients with or without low cardiac output syndrome (n = 35, n = 16, respectively) showed significant differences in repeated measurement time points (p = 0.0001). The preoperative brain natriuretic peptide cut‐off value of 125.5 pg mL‐1 was found to have the highest sensitivity of 88.9% and specificity of 96.9% in predicting low cardiac output syndrome in patients with pulmonary hypertension. A good correlation was found between preoperative plasma brain natriuretic peptide level and duration of mechanical ventilation (r = 0.67, p = 0.0001).

Conclusions

In patients with pulmonary hypertension undergoing congenital heart surgery, 91% of patients with preoperative plasma brain natriuretic peptide levels above 125.5 pg mL‐1 are at risk of developing low cardiac output syndrome which is an important postoperative outcome.     

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.     

Avaliação do programa de aprimoramento em anestesia cardiovascular por seus ex‐estagiários

Background

After advancement of cardiovascular surgery, there is also exponential development of anesthetic techniques in this field. Patients with increasing clinical complexity challenge cardiac anesthesiologists to keep constantly updated. An evaluation of Brazilian's cardiovascular anesthesia fellowship at Dante Pazzanese Institute of Cardiology has been made and information has been collected to evaluate the fellowship program in cardiovascular anesthesia.

Preditores de mortalidade intra‐hospitalar em pacientes submetidos a cirurgias não eletivas em um hospital universitário: uma coorte prospectiva

Introduction

Morbidity and mortality associated with urgent or emergency surgeries are high compared to elective procedures. Perioperative risk scores identify the non‐elective character as an independent factor of complications and death. The present study aims to characterize the population undergoing non‐elective surgeries at the Hospital de Clínicas de Porto Alegre and identify the clinical and surgical factors associated with death within 30 days postoperatively.

Infusão intraoperatória de esmolol reduz o consumo pós‐operatório de analgésicos e o uso de anestésico durante a septorrinoplastia: estudo randômico

Background and objectives

Esmolol is known to have no analgesic activity and no anaesthetic properties; however, it could potentiate the reduction in anaesthetic requirements and reduce postoperative analgesic use. The objective of this study is to evaluate the effect of intravenous esmolol infusion on intraoperative and postoperative analgesic consumptions as well as its effect on depth of anaesthesia.

Method

This randomized‐controlled double blind study was conducted in a tertiary care hospital between March and June 2010. Sixty patients undergoing septorhinoplasty were randomized into two groups. History of allergy to drugs used in the study, ischaemic heart disease, heart block, bronchial asthma, hepatic or renal dysfunction, obesity and a history of chronic use of analgesic or β‐blockers were considered cause for exclusion from the study. Thirty patients received esmolol and remifentanil (esmolol group) and 30 patients received normal saline and remifentanil (control group) as an intravenous infusion during the procedure. Mean arterial pressure, heart rate, and bispectral index values were recorded every 10 min. Total remifentanil consumption, visual analogue scale scores, time to first analgesia and total postoperative morphine consumption were recorded.

Results

The total remifentanil consumption, visual analogue scale scores at 0, 20 and 60 min, total morphine consumption, time to first analgesia and the number of patients who needed an intravenous morphine were lower in the esmolol group.

Conclusions

Intravenous infusion of esmolol reduced the intraoperative and postoperative analgesic consumption, reduced visual analogue scale scores in the early postoperative period and prolonged the time to first analgesia; however it did not influence the depth of anaesthesia.     

Propofol‐cetamina versus dexmedetomidina‐cetamina para sedação durante endoscopia digestiva alta em pacientes pediátricos: estudo clínico randomizado

Background and objectivesDay‐case pediatric sedation is challenging. Dexmedetomidine is a sedative analgesic that does not induce respiratory depression. We compared dexmedetomidine to propofol when it was added to ketamine for sedation during pediatric endoscopy, regarding recovery time and hemodynamic changes.MethodsWe enrolled 120 patients (2−7 years in age) and randomly assigned them into two groups. Each patient received intravenous (IV) ketamine at a dose of 1 mg.kg^‐1 in addition to either propofol (1 mg.kg^‐1) or dexmedetomidine (0.5 μg.kg^‐1). The recovery time was compared. Hemodynamics, oxygen saturation, need for additional doses, postoperative complications and endoscopist satisfaction were monitored.ResultsThere was no significant difference in hemodynamics between the groups. The Propofol‐Ketamine (P‐K) group showed significantly shorter recovery times than the Dexmedetomidine‐Ketamine (D‐K) group (21.25 and 29.75 minutes respectively, p < 0.001). The P‐K group showed more oxygen desaturation. Eleven and six patients experienced SpO₂ < 92% in groups P‐K and D‐K, respectively. A significant difference was noted regarding the need for additional doses; 10% of patients in the D‐K group needed one extra dose, and 5% needed two extra doses, compared to 25% and 20% in the P‐K group, respectively (p = 0.001). The P‐K group showed less post‐procedure nausea and vomiting. No statistically significant difference between both groups regarding endoscopist satisfaction.ConclusionsThe P‐K combination was associated with a shorter recovery time in pediatric upper gastrointestinal endoscopy, while the D‐K combination showed less need for additional doses.Registration numberClinical trials.gov (NCT02863861).     

Avaliação dos efeitos neurotóxicos da administração intratecal do (S)‐(+)‐cetoprofeno em medula espinhal de rato: estudo experimental randômico e controlado

Background and objectivesIntrathecal administration of non‐steroidal anti‐inflammatory drugs is more efficacious for post‐operative pain management. Cyclooxygenase inhibiting non‐steroidal anti‐inflammatory drugs like (S)‐(+)‐Ketoprofen, may be effective at lower intrathecal doses than parenteral ones. Preclinical safety regarding possible neurotoxicity associated with the intrathecal (S)‐(+)‐Ketoprofen was not evaluated. Here we analysed the neurotoxicity of intrathecally administered (S)‐(+)‐Ketoprofen in rats.MethodsA randomized placebo‐controlled experimental study was conducted. Sprague‐Dawley rats (250–300 g) aged 12–16 weeks were randomly divided into 2 treatments [100 and 800 μg (S)‐(+)‐Ketoprofen] and control (sterile water) groups. Intrathecal catheters were placed via the atlantoaxial space in anesthetized rats. Pinch‐toe tests, motor function evaluations and histopathological examinations of the spinal cord and nerve roots were performed at days 3, 7 and 21. Spinal cord sections were evaluated by light microscopy for the dorsal axonal funiculus vacuolation, axonal myelin loss, neuronal chromatolysis, neuritis, meningeal inflammation, adhesions, and fibrosis.ResultsRats in all the groups exhibited normal pinch‐toe testing response (score = 0) and normal gait at each observed time (motor function evaluation score = 1). Neurotoxicity was higher with treatments on days 3 and 7 than that on day 21 (2, 3, 0, p = 0.044; 2, 5, 0, p = 0.029, respectively). On day 7, the total scores reflecting neuronal damage were higher in the 800 μg group than those in the 100 μg and Control Groups (5, 3, 0, p = 0.048, respectively).ConclusionIntrathecal (S)‐(+)‐Ketoprofen caused dose‐dependent neurohistopathological changes in rats on days 3 and 7 after injection, suggesting that (S)‐(+)‐Ketoprofen should not be intrathecally administered.     

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.

A aplicação desnecessária de cateterização venosa central em pacientes cirúrgicos

Background and objectives

Perioperative physicians occasionally encounter situations where central venous catheters placed preoperatively turn out to be unnecessary. The purpose of this retrospective study is to identify the unnecessary application of central venous catheter placement and determine the factors associated with the unnecessary application of central venous catheter placement.