Shock anafiláctico versus síndrome de Kounis durante el intraoperatorio de cirugía cardiaca: diagnóstico diferencial

Although Kounis syndrome was described almost 3 decades ago, there has been a notable increase in the reports of cases of acute coronary syndromes developed in the context of allergic reactions, also known as Kounis syndrome. This article discusses the diagnostic possibility in the face of an acute biventricular failure in the course of an anaphylactic reaction during the intra-operative period of a cardiac valve surgery.     

Comparação dos efeitos de remifentanil e remifentanil + lidocaína em intubação de pacientes intelectualmente deficientes

Background and objectives

This is a prospective, randomized, single‐blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents.

Methods

Fifty intellectually disabled, American Society of Anesthesiologists I–II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 μg/kg remifentanil (Group 1, n = 25) or a combination of 2 μg/kg remifentanil and 1 mg/kg lidocaine (Group 2, n = 25). To evaluate intubation conditions, Helbo‐Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO₂) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation.

Results

Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra‐group comparisons, the heart rate and mean arterial pressure values at all‐time points in both groups showed a significant decrease compared to baseline values (p = 0.000)

Conclusion

By the addition of 2 μg/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually disabled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1 mg/kg lidocaine to 2 μg/kg remifentanil does not provide any additional improvement in the intubation parameters.     

Desenvolvimento de fibrilação ventricular por causa de etomidato para indução anestésica: um efeito colateral muito raro,relato de caso

Background and objectives

Ventricular fibrillation occurring in a patient can result in unexpected complications. Here, our aim is to present a case of ventricular fibrillation occurring immediately after anesthesia induction with etomidate administration.

Case report

A fifty‐six‐year‐old female patient with a pre‐diagnosis of gallstones was admitted to the operating room for laparoscopic cholecystectomy. The induction was performed by etomidate with a bolus dose of 0.3 mg/kg. Severe and fast adduction appeared in the patient's arms immediately after induction. A tachycardia with wide QRS and ventricular rate 188 beat/min was detected on the monitor. The rhythm turned to VF during the preparation of cardioversion. Immediately we performed defibrillation to the patient. Sinus rhythm was obtained. It was decided to postpone the operation due to the patient's unstable condition.

Conclusion

In addition to other known side effects of etomidate, very rarely, ventricular tachycardia and fibrillation can be also seen. To the best of our knowledge, this is the first case regarding etomidate causing VF in the literature.     

Comparação entre os efeitos de dexmedetomidina,fentanil e esmolol na prevenção da resposta hemodinâmica à intubação

Background and objectives

Laryngoscopy and intubation can cause hemodynamic response. Various medications may be employed to control that response. In this study, we aimed to compare the effects of dexmedetomidine, fentanyl and esmolol on hemodynamic response.

Method

Ninety elective surgery patients who needed endotracheal intubation who were in American Society of Anesthesiology I–II group and ages between 21 and 65 years were included in that prospective, randomized, double‐blind study. Systolic, diastolic, mean arterial pressures, heart rates at the time of admittance at operation room were recorded as basal measurements. The patients were randomized into three groups: Group I (n = 30) received 1 μg/kg dexmedetomidine with infusion in 10 min, Group II (n = 30) received 2 μg/kg fentanyl, Group III received 2 mg/kg esmolol 2 min before induction. The patients were intubated in 3 min. Systolic, diastolic, mean arterial pressures and heart rates were measured before induction, before intubation and 1, 3, 5, 10 min after intubation.

Results

When basal levels were compared with the measurements of the groups, it was found that 5 and 10 min after intubation heart rate in Group I and systolic, diastolic, mean arterial pressures in Group III were lower than other measurements (p < 0.05).

Conclusions

Dexmedetomidine was superior in the prevention of tachycardia. Esmolol prevented sytolic, diastolic, mean arterial pressure increases following intubation. We concluded that further studies are needed in order to find a strategy that prevents the increase in systemic blood pressure and heart rate both.     

Monitoramento dos efeitos da raquianestesia sobre a saturação de oxigênio cerebral em pacientes idosos com o uso de espectroscopia de luz próxima ao infravermelho

Objective

Central blockage provided by spinal anaesthesia enables realization of many surgical procedures, whereas hemodynamic and respiratory changes influence systemic oxygen delivery leading to the potential development of series of problems such as cerebral ischemia, myocardial infarction and acute renal failure. This study was intended to detect potentially adverse effects of hemodynamic and respiratory changes on systemic oxygen delivery using cerebral oxymetric methods in patients who underwent spinal anaesthesia.

Methods

Twenty‐five ASA I–II Group patients aged 65–80 years scheduled for unilateral inguinal hernia repair under spinal anaesthesia were included in the study. Following standard monitorization baseline cerebral oxygen levels were measured using cerebral oximetric methods. Standardized Mini Mental Test (SMMT) was applied before and after the operation so as to determine the level of cognitive functioning of the cases. Using a standard technique and equal amounts of a local anaesthetic drug (15 mg bupivacaine 5%) intratechal blockade was performed. Mean blood pressure (MBP), maximum heart rate (MHR), peripheral oxygen saturation (SpO₂) and cerebral oxygen levels (rSO2) were preoperatively monitored for 60 min. Pre‐ and postoperative haemoglobin levels were measured. The variations in data obtained and their correlations with the cerebral oxygen levels were investigated.

Results

Significant changes in pre‐ and postoperative measurements of haemoglobin levels and SMMT scores and intraoperative SpO₂ levels were not observed. However, significant variations were observed in intraoperative MBP, MHR and rSO2 levels. Besides, a correlation between variations in rSO2, MBP and MHR was determined.

Conclusion

Evaluation of the data obtained in the study demonstrated that post‐spinal decline in blood pressure and also heart rate decreases systemic oxygen delivery and adversely effects cerebral oxygen levels. However, this downward change did not result in deterioration of cognitive functioning.     

Síndrome de Kounis tras administración de rocuronio

Kounis syndrome encompasses concepts including angina and allergic infarction described in relation to exposure to different allergens. The aim of this article is to describe a case of Kounis Syndrome type II after exposure to rocuronium as well as the patholophysiology and the treatment of this syndrome.     

Síndrome de Kounis del tipo II inducido por amoxicilina-ácido clavulánico complicado con encefalopatía hipóxico-isquémica durante anestesia general

Anaphylaxis is a severe acute multisystem syndrome involving massive mediator release from mast cells and basophils. Although the entire arterial system can be affected, when coronary arteries are the main targets, Kounis syndrome needs to be considered. Cerebral artery involvement has also been suggested in rarer MC-mediator release episodes; so-called ‘Kounis-like’ syndrome. Cerebral ischaemic lesions can then result from low blood pressure or direct proinflammatory and/or vasoconstrictive mediator action in the cerebral arterial system. Diagnosis can be difficult in anaesthetised patients, as low blood pressure can have multiple causes. Treatment is also challenging, as administering adrenaline can worsen ischaemia. We report the first case of amoxicillin-clavulanic acid-induced type II Kounis syndrome under general anaesthesia, complicated with severe, irreversible and subsequently fatal encephalopathy of ischaemic origin. This case can contribute to awareness of less common Kounis syndrome manifestations, including severe cerebral involvement, or other anaphylactic reactions with atypical presentations.     

A estruturação de um serviço de cuidados paliativos no Brasil: relato de experiência

Background and objectives

In Brazil, palliative care (PC) is not properly structured and that reality transforms this theme in a public health problem; therefore, initiatives become relevant in this context. This paper aims to share the experience that occurred in an oncology referral hospital in the State of Maranhão and present initiatives that helped in the development of PC Service.

Experience report

The hospital had an outpatient Pain and PC Service, but without specialized beds. The terminally ill patients stayed in common wards, which caused much unrest. A sensitization process was initiated in the hospital through initiatives, such as a photo contest called Flashes of Life and a ward called Room of Dreams, designed in partnership with the architecture course at the Universidade Estadual do Maranhão. The process culminated in the granting of wards to the PC and in the commitment of the Foundation, sponsor of the hospital, to run the project.

Conclusion

This experience was a reproducible local initiative for the establishment of PC in a cancer hospital. Local initiatives are valuable in Brazil because they favor a significant number of patients and show its effectiveness in practice to governments and society. To structure a PC service, it is essential to establish priorities that include the assignment of drugs for management of symptoms, humanization, multidisciplinarity, sensitization and education of professionals.     

Comparação de esmolol em bolus e infusão contínua na resposta hemodinâmica à laringoscopia,intubação orotraqueal e esternotomia em cirurgia de revascularização coronária

Background and objective

The aim of this randomized, prospective and double blinded study is to investigate effects of different esmolol use on hemodynamic response of laryngoscopy, endotracheal intubation and sternotomy in coronary artery bypass graft surgery.

Methods

After approval of local ethics committee and patients’ written informed consent, 45 patients were randomized into three groups equally. In Infusion Group; from 10 min before intubation up to 5th minute after sternotomy, 0.5 mg/kg/min esmolol infusion, in Bolus Group; 2 min before intubation and sternotomy 1.5 mg/kg esmolol IV bolus and in Control Group; %0.9 NaCl was administered. All demographic parameters were recorded. Heart rate and blood pressure were recorded before infusion up to anesthesia induction in every minute, during endotracheal intubation, every minute for 10 minutes after endotracheal intubation and before, during and after sternotomy at first and fifth minutes.

Results

While area under curve (AUC) (SAP × time) was being found more in Group B and C than Group I, AUC (SAP × Tint and Tst) and AUC (SAP × T2) was found more in Group B and C than Group I (p < 0.05). Moreover AUC (HR × Tst) was found less in Group B than Group C but no significant difference was found between Group B and Group I.

Conclusion

This study highlights that esmolol infusion is more effective than esmolol bolus administration on controlling systolic arterial pressure during endotracheal intubation and sternotomy in CABG surgery.     

Coronary bypass without angiography: an unusual circumstance

This paper presents an unusual case of an individual with myocardial ischemia, angina pectoris, and myocardial infarction who also had an anaphylactic reaction to angiographic dye. The coronary bypass operation was guided by the use of intraoperative coronary reactive hyperemia assessed by Doppler ultrasound. The patient has had a good response to the operation without additional angina or difficulties.     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.     

Acute left ventricular dysfunction due to Tako-tsubo syndrome after induction of general anesthesia

Tako-tsubo cardiomyopathy is a recently described form of transient ventricular dysfunction that is not associated with coronary vessels obstruction, although its clinical manifestations are often similar to those of myocardial ischemia. This syndrome is possibly due to an excess of catecholamines, and it is associated with emotional and physical stress and surgery. However, the pathophysiological relation to anaesthesia has not yet been clarified. We report a case of Tako-tsubo cardiomyopathy that ensued immediately after induction of general anaesthesia for elective surgery in a patient submitted to laparoscopic cholecystectomy. The patient was first treated as if affected by myocardial ischemia, but a rapidly performed emergency coronary angiography showed normal epicardial coronary vessels with a significant reduction of left ventricular function. The coronary angiography ruled out the diagnosis of typical myocardial ischemia and allowed for the arrival at the correct diagnosis. The transient ventricular ballooning was attributed to the recently described Tako-tsubo syndrome. Prompt treatment allowed control of symptoms, and the patient was safely treated and discharged on day 15. Although it is difficult to identify the cause of this syndrome, it may be argued that, during general anaesthesia and particularly at induction, the imperfect control of catecholamine excess may induce cardiac damage in predisposed subjects.     

Remifentanil post‐conditioning attenuates cardiac ischemia–reperfusion injury via κ or δ opioid receptor activation

Background: Ischemic pre‐ or post‐conditioning of the heart has been shown to involve opioid receptors. Remifentanil, an ultra‐short‐acting selective μ opioid receptor agonist in clinical use, pre‐conditions the rat heart against ischemia–reperfusion injury. This study investigates whether remifentanil post‐conditioning is also cardioprotective. Methods: Remifentanil post‐conditioning (5‐min infusion at 1, 5, 10 or 20 μg/kg/min) or ischemic post‐conditioning (three cycles of a 10 s reperfusion interspersed with a 10 s ischemia) was induced in an open‐chest rat heart model of ischemia and reperfusion injury, in the presence or absence of nor‐binaltorphimine, naltrindole or CTOP, specific κ, δ and μ opioid receptor antagonists, respectively. The same sequence of experiments was repeated in the isolated heart model using the maximal protective dose of remifentanil from the dose–response studies. Results: Both ischemic and remifentanil post‐conditioning reduced the myocardial infarct size relative to the control group in both models. This cardioprotective effect for both post‐conditioning regimes was prevented by the prior administration of nor‐binaltorphimine and naltrindole but not CTOP. The sole administration of the antagonists had no effect on the size of myocardial infarction. Conclusions: These results indicate that remifentanil post‐conditioning protects the heart from ischemia–reperfusion injury to a similar extent as of ischemic post‐conditioning. This protection involves κ and δ but not μ opioid receptor activation. This drug has great potential as a clinical post‐conditioning modality as it can be given in large doses without prolonged opioid‐related side effects.     

A case of severe coronary artery spasm associated with anaphylactic reaction caused by protamine administration

A 65-year-old man with mitral regurgitation and atrial fibrillation underwent mitral valve plasty and Maze's operation. Cardiopulmonary bypass (CPB) was finished uneventfully. But after protamine administration, severe systemic hypotension occurred suddenly with electrocardiographic ST-segment elevation and wide QRS intervals. We thought that this reaction had been caused by coronary spasm and not by anaphylactic reaction because he was without typical anaphylactic manifestations such as general rash and bronchospasm. We administered epinephrine, methylprednisolone, heparin for restarting CPB, and used IABP support to assist systemic circulation. We again tried to administer protamine to neutralize the anticoagulative effect of heparin when his vital sign had recovered, but the same reaction occurred immediately with small amounts of protamine. The second CPB was necessary for some time. This case suggests that coronary artery spasm associated with anaphylactic reaction was induced by administration of protamine. It is known that intravenous protamine administration sometimes causes adverse events. As in this case, we should consider the possibility of severe coronary spasm associated with anaphylactoid reaction even if other symptoms of anaphylactic reactions such as cutaneous manifestation and bronchospasm are not present.     

Remoção endovascular percutânea de cateter totalmente implantável com migração intracardíaca em criança com leucemia linfoblástica aguda

A 2‐year‐old boy with acute lymphoblastic leukemia was presented with peripherally inserted central catheter dysfunction. Radiological examinations revealed a catheter remnant in the right atrium extending into pulmonary vein. The catheter remnant was successfully removed from the right atrium by percutaneous endovascular intervention without any complications.     

Intradermal skin testing in the investigation of suspected anaphylactic reactions during anaesthesia--a retrospective survey

An anaphylactic reaction is a rare, but severe anaesthetic complication. In this retrospective survey we report on patients with a severe suspected anaphylactic reaction during anaesthesia and the investigation with intradermal skin testing of these suspected anaphylactic reactions. In the patients with an anaphylactic reaction to neuromuscular blocking drugs, the subsequent anaesthetic history was examined. Sixty-five patients suffered a suspected anaphylactic reaction between 1976 and 2001. In 47 patients skin testing was performed and 43 of these patients had positive skin tests: neuromuscular blockings drugs and succinylcholine more specifically, were the most frequently incriminated drugs. After the anaphylactic reaction 19 patients had surgery on 26 occasions with the use of a skin-test-negative neuromuscular blocking drug; no problems occurred. Skin testing proved to be a reliable tool to investigate suspected anaphylactic reactions during anaesthesia and to guide the future use of neuromuscular blocking drugs.     

Duodenal Necrosis and Nonvariceal Digestive Bleeding After Terlipressin Administration for Treatment of Hepatorenal Syndrome: a Case Report of a Novel Side Effect of a Commonly Used Drug

BackgroundTerlipressin is widely used for treatment of hepatorenal syndrome and variceal bleeding in cirrhotic patients. However, it may be associated with side effects, especially those related to vasoconstriction, such as myocardial infarction or intestinal ischemia. This is a case report of a cirrhotic patient with nonvariceal upper gastrointestinal bleeding after duodenal necrosis due to the use of terlipressin, a novel side effect not yet described in literature to the best of our knowledge.Case reportA 51-year-old male patient, with alcoholic liver cirrhosis and hepatitis C virus infection, was admitted presenting oliguria associated with severe ascites and lower limb edema. His Model for End Stage Liver Disease–Sodium score was 19 and his serum creatine level was 2.12 mg/dL. Albumin infusion was performed for 48 hours, but his serum creatinine level reached 3.46 mg/dL. Terlipressin infusion was started in continuous infusion and serum creatinine levels progressively decreased. However, the patient presented hemorrhagic shock secondary to hematemesis after 7 days. Upper digestive endoscopy showed an extensive ulcerated lesion in the duodenal bulb, reaching 70% of its lumen, with hematic residues and necrotic foci. Terlipressin was suspended and proton pump inhibitors were started. Despite intensive care, the patient developed severe encephalopathy and reentrant seizures. He eventually died 10 days after the bleeding event.ConclusionsWe described a case of nonvariceal upper gastrointestinal bleeding secondary to duodenal necrosis, which was caused by visceral ischemia induced by terlipressin. Given its fatality potential, this novel side effect should be remembered when using this medication in cirrhotic patients.     

Late compartment syndrome of the hand due to wasp sting in a child

We report a 6-year-old girl, with no history of previous anaphylactic reaction, who sustained a wasp sting to the volar aspect of her left hand. The child did not present any symptoms at the beginning. She was first examined at the emergency department with developed compartment syndrome, after more than 24 hours later and she was urgently taken to the operating theatre. The midpalmar, thenar, and hypothenar spaces were decompressed, and the transverse carpal ligament was released. At the 11-month followup, she presented with normal function of the hand and normal 2-point discrimination in all fingers. Although the accurate mechanism of the development of compartment syndrome after a wasp sting in children is not thoroughly clear, the treatment seems to be the same as in all other cases of compartment syndrome; urgent fasciotomy. It is very important to keep in mind the possibility, even if it is extremely low, of compartment syndrome after a wasp sting in children; even of those with no history of anaphylactic reaction.     

Cardiac ischemia during hemolytic uremic syndrome

Increased thrombin generation and impaired fibrinolysis during Escherichia coli O157:H7-associated hemolytic uremic syndrome (HUS) plausibly diminish myocardial blood flow, but the frequency of cardiac ischemia during HUS is unknown. We identified a 9-year-old boy with HUS in whom myocardial diastolic dysfunction was demonstrated by echocardiography, who also had elevated serum troponin-I and creatine kinase MB mass. However, eight additional patients with HUS did not have elevated markers of cardiac injury. When present, elevated troponin-I should be considered to represent myocardial injury, and not attributed simply to renal insufficiency. It is possible that myocardial ischemia and secondary arrhythmias account for some sudden deaths that occur during acute HUS.     

How to reliably detect ischemia in the intensive care unit and operating room

Detection of myocardial ischemia in the perioperative period is important because it allows for intervention that may prevent progression of ischemia to myocardial infarction. Perioperative ischemia is also an important predictor of adverse cardiovascular outcomes. Patients should first be stratified according to their risk of having cardiovascular disease by identifying major, intermediate, and minor predictors of adverse cardiovascular outcome. Electrocardiographic (ECG) monitoring for ischemia is inexpensive and noninvasive, but may not be applicable to all patients and is not perfectly sensitive or specific. Modern operating room monitors can automate ST segment monitoring and be set to alarm if changes occur. Increases in central venous pressure and pulmonary artery pressure can be caused by myocardial ischemia, but have been shown to be very insensitive compared to ECG. Also, detection of these hemodynamic changes requires insertion of invasive monitoring devices. Transesophageal echocardiography can be used to detect myocardial ischemia by identifying changes in regional wall motion. These transesophageal echocardiography changes occur sooner and more frequently than ECG changes, but require greater knowledge and skill to properly interpret.