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.

Avaliação do tempo de atraso do índice bispectral na resposta à indução da anestesia: estudo observacional

Background and objectivesAccording to the manufacturer, the Bispectral Index (BIS) has a processing time delay of 5–10 s. Studies addressing this have suggested longer delays. We evaluated the time delay in the Bispectral Index response.MethodsBased on clinical data from 45 patients, using the difference between the predicted and the real BIS, calculated during a fixed 3 minutes period after the moment the Bispectral Index dropped below 80 during the induction of general anesthesia with propofol and remifentanil.ResultsThe difference between the predicted and the real BIS was in average 30.09 ± 18.73 s.ConclusionOur results may be another indication that the delay in BIS processing may be much longer than stated by the manufacture, a fact with clinical implications.     

Avaliação do comprometimento respiratório em pacientes com lúpus eritematoso sistêmico com o teste de caminhada de seis minutos

ObjectiveEvaluate SLE stable patients, without overt respiratory compromise, by means of 6 MWT.Casuistic and methodsForty‐five stable SLE patients were enrolled. The ATS/ERS protocol for 6 MWT, was used and two parameters with cut‐off points were chosen.ResultsForty‐two patients were women. The mean age was 39 ± 11.4 years; mean duration of disease, 121 ± 93.1 months; mean value of MRC, 2 ± 0; mean FVC, 85.9 ± 34.2%; meanFEV1, 67.5 ± 21.6%; mean MIP, 82 ± 58.4%; mean MEP, 78 ± 37.3%; mean heart rate at rest, 75 ± 12.8 bpm; mean respiratory rate at rest, 19 ± 5.3 bpm; mean 6 MWD, 478 ± 82 m; mean SpO2 at rest was 98 ± 0.8%; mean fall in SpO2, 4 ± 6 points. When the study population was divided according to the 400‐m walk distance cut‐off value, the heart rate immediately before the test was significant lower in those participants who walked less than 400 m (p = 0.0043), just like the value of Borg scale (p = 0.0036); according to the presence of saturation≥ 4, heart rate at the end of the test was significantly higher in those participants who were showing desaturation (p = 0.0170); MEP (p = 0.0282) and 6 MWD (p = 0.0291) were significantly lower, and MIP showed a tendency towards being smaller (p = 0.0504). FVC < normal inferior limit was significantly associated with the group with desaturation (p = 0.0274).ConclusionCompared to 6 MWD, desaturation was better suited to find the patients with the most compromised indexes in respiratory function tests.     

Composição corporal por absorciometria radiológica de dupla energia de mulheres com fibromialgia

ObjectivesTo assess body composition in women with fibromyalgia (FM) comparing to the reference value for healthy women.Patients and MethodsCross‐sectional observational analytical study, with 52 women selected with Fibromyalgia, according American College of Rheumatology (ACR, 1990) criteria. The patients were selected in Hospital de Clínicas da Universidade Federal do Paraná (HC‐UFPR) and divided into two groups, 28 patients with a BMI (Body Mass Index) equal or higher (≥) than 25 kg/m2 and 24 patients with BMI less or equal (≤) 24.99 kg/m2, subjected to physical examination for the count of tender points (TP) and completing the fibromyalgia impact questionnaire (FIQ). The assessment of body composition was performed by the Dual‐Energy X‐Ray Absorptiometry (DXA). The values of the fat mass percentage (MG %) found in the two groups were compared to the average percentage of MG by age and sex, described by Heward (2004).ResultsThe mean age of the study groups was 47.8 ± 8.6 years, the FIQ score was 70.5 ± 18.6 and TP 16.2 ± 2.0. The mean BMI was 26.4 ± 4.1 kg/m2, and the amount of MG was 25.2 ± 7.8 kg and 39.5 ± 6.8%, and lean mass (LM) was 37 2 ± 3.7 kg and 60.4 ± 7.3%. In the group with BMI ≤ 25 kg/m2, the MG % was 33.8% (21.5 ‐42.4) and in the group with BMI ≥ 25 kg/m2 of the MG was 44.4% (37.6 ‐56.2).ConclusionBoth groups women with FM eutrophic as the overweight and obese group, presented higher reference MG% levels comparing with the standard levels for healthy women.     

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.

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.

Avaliação da aterosclerose subclínica e de níveis plasmáticos de LDL minimamente modificada em pacientes com espondilite anquilosante e sua correlação com a atividade da doença

IntroductionAccelerated atherosclerosis has been shown in some autoimmune diseases, mainly in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Although high preva- lence of corticosteroids use may be a confounding factor due to their detrimental effects on several risk factors, systemic inflammation per se is supposed to play an important role in atherogenesis in these patients.MethodsWe have evaluated sub-clinical atherosclerosis and plasma levels of circulating electronegative LDL, which represents the fraction of LDL that is minimally modified, in patients with ankylosing spondylitis (AS). Fourteen patients who fulfilled the modified New York criteria for AS were compared with 13 paired controls. Carotid intimal-media thick- ness (IMT) was assessed by ultrasonography bilaterally in common carotid artery, internal carotid artery and in the bifurcation. Groups were homogeneous regarding cardiovascular risk factors. Only a single patient in AS group was in use of corticosteroid.ResultsThe presence of active inflammation was demonstrated by elevated BASDAI and higher CRP levels and in patients versus controls (12.36 vs. 3.45 mg/dl, P = 0.002). No dif- ference was found in carotid IMT between both groups, in any site of artery. Averaged IMT (6 measurements, at 3 pre-specified sites bilaterally) was 0.72 ± 0.28 in AS group and 0.70 ± 0.45 mm in controls (P = 0.91). Minimally modified LDL did not differ significantly either between patients and controls (14.03 ± 17.40 vs. 13.21 ± 10.21; P = 0.88).ConclusionsPatients with AS did not show increased carotid IMT in comparison to con- trols. In the same way, circulating plasma levels of LDL (-), did not differ significantly in both groups.     

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.     

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.     

Análise sistemática da influência do antifator de necrose tumoral [anti-TNF] sobre as taxas de infecção em pacientes com artrite reumatoide

ObjectiveThe present article aims to provide a systematic review of the influence of anti- tumor necrosis factor (TNF) on infection rates in patients with rheumatoid arthritis (RA).MethodMedline was searched to obtain quality control information on infection rates in RA patients treated with anti-TNF.ResultsA high proportion of RA patients are now established users of anti-TNF agents. Data from national registries in European countries of patients with RA treated with anti-TNF suggest that biological therapies are closely linked to sepsis. Although previous studies reported a higher risk of infections, there are now emerging data with longer duration of follow-up that suggested an adjusted hazard risk of 1.2. Elderly patients and those with longstanding disease may have a higher rate of serious infections compared to their coun- terparts who were younger with early disease. There are now emerging data to suggest that anti-TNF therapy is associated with the development of neutropenia shortly after the commencement of treatment. The biologic registries found that RA patients treated with monoclonal antibodies are at increased risk of tuberculosis (TB) compared to those on TNF receptor blockers. This risk of infection needs to be weighed against the established ben- efits of TNF blockers.ConclusionCurrent evidence suggests that anti-TNF treatment in RA is closely linked to infection. Patients need to be aware of the risk of infection together with the established benefits of TNF blockers in order to give informed consent for treatment.     

Efeito de informações por meio de vídeo sobre a ansiedade e satisfação de pacientes submetidos à anestesia espinhal

Background

Providing sufficient information during a preanesthetic interview may help improve patient understanding and decrease anxiety related to spinal anesthesia. We investigated the effect of video‐based education on anxiety and satisfaction in patients about to undergo spinal anesthesia.

Eficácia de bupivacaína e associação com dexmedetomidina em bloqueio do plano transverso abdominal guiado por ultrassom na dor após cirurgia abdominal

Background and objectives

We aimed to evaluate the effect of bupivacaine and dexmedetomidine added to bupivacaine used in tranversus abdominis plane (TAP) block on postoperative pain and patient satisfaction in patients undergoing lower abdominal surgery.

Análise da associação da fadiga com variáveis clínicas e psicológicas em uma série de 371 pacientes brasileiros com artrite reumatoide

ObjectivesFatigue is a highly subjective and extremely common symptom in patients with rheumatoid arthritis although it is difficult to characterize and define. The aim of this study was to assess fatigue in a cohort of Brazilian patients, and to analyze the relationship between fatigue and disease‐specific variables.Methods371 Brazilian patients diagnosed with rheumatoid arthritis according to the 1987 American College of Rheumatology classification criteria were prospectively investigated. Demographic, clinical and laboratorial data were obtained from hospitals records. The number of painful joints, bone mass index, disease duration, quality of life, functional capacity, anxiety and depression were recorded. Fatigue was evaluated using the subscale of Fatigue Assessment of Chronic Illness Therapy (FACIT‐FATIGUE scale).ResultsThe median fatigue score was 42.0 (10.0), negatively correlated with functional capacity (‐0.507; P < 0.001), anxiety and depression (‐0.542 and ‐0.545; P < 0.001 respectively), and predominantly with physical domain of Short Form 36‐item quality of life questionnaire (SF‐36P: 0.584; P < 0.001). The scores were not associated with the erythrocyte sedimentation rate (‐0.118; P < 0.05), C‐reactive protein (‐0.089; P < 0.05), disease activity (‐0.250; P < 0.001) or the number of painful joints (‐0.135; P < 0.01). Confidence interval of 95% was applied for all measures.ConclusionsIn this series of Brazilian patients with rheumatoid arthritis, we suggest a new significance for fatigue complains as an independent parameter not related with number of painful joints, disease or inflammatory activity scores. Psychological and functional impairments appear to be more related to fatigue. Additional studies and inclusion of standard measures for monitoring fatigue complains are required.     

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.

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.

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.     

Avaliação da qualidade da recuperação e do estado de saúde no pós‐operatório de cirurgias eletivas

Purpose

Postoperative recovery is a complex process with physiologic, functional, and psychologic dimensions. Postoperative quality of recovery is considered as a crucial outcome following surgery and anesthesia. The objective of this study was to assess and compare the quality of postoperative recovery and health status before and after surgery, in patients undergoing elective surgery.

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.     

Exposição à periodontite no intervalo de um ano antes do tratamento antidiabético e risco de artrite reumatoide em pacientes com diabete mellitus: estudo de coorte populacional

ObjectiveTo examine whether a history of periodontitis (PD) before anti-diabetic treatment is associated with risk of rheumatoid arthritis (RA) development in newly-treated diabetes mellitus (DM) patients.MethodsWe conducted a population-based retrospective cohort study using the 1997-2009 National Health Insurance (NHI) claims data of one million representative individuals from all NHI enrollees. Adults with DM (aged ≥20 years) starting anti-diabetic treatment during 2001–2009 were classified as newly-treated DM patients. We identified 7097 DM subjects with PD history within one year before initiating anti-diabetes treatment (index date). By matching these 7097 subjects for age on the index date, sex, and year of the index date, we randomly extracted 14,194 DM subjects without PD history within one year before antidiabetic treatment. Adjusted hazard ratios (aHRs) with a 95% confidence interval (CI) were calculated by applying Cox proportional hazards models to quantify the association between PD history and RA risk.ResultsCompared with DM patients without PD exposure within one year before anti-diabetic treatment, crude HR and adjusted HR of RA among DM patients with PD exposure within one year before anti-diabetic treatment were 4.51 (95% CI, 1.39–14.64) and 3.77 (95% CI, 1.48–9.60).ConclusionPD exposure within one year before anti-diabetic treatment was associated with increased RA risk in newly treated DM patients. The lack of knowledge about individual smoking status is a major limitation of this study.