Reposição de volume orientada pela variação da pressão de pulso durante transplante renal: estudo randomizado controlado

PurposeKidney transplantation is the gold‐standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV‐guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study.MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the PPV Group received fluids whenever PPV was higher than 12%, patients in the Free Fluid Group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg^‐1.h^‐1).ResultsUrinary output was similar at every time‐point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge.ConclusionPPV‐guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.     

Relação entre consumo de tabaco e concentração de monóxido de carbono na expiração com complicações respiratórias perioperatórias

Background

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

Antinocicepção intravenosa sem opioides orientada pelo Índice de Analgesia/Nocicepção: relato de caso

BackgroundOpioid‐free anesthesia decreases the incidence of opioid adverse events, but its optimal antinociceptive depth has not been clearly defined. Personalizing intraoperative opioid‐free infusions with a nociception monitor may be the solution.Case reportWe describe the feasibility and potential limitations of titrating opioid‐free antinociception during major abdominal surgery using the Analgesia Nociception Index (Mdoloris, Lille, France) in an obese patient. After stabilizing the patient's nociception‐antinociception balance intraoperatively we quickly reversed anesthesia and the patient did not require postoperative opioids.ConclusionPersonalizing opioid‐free antinociception with a nociception monitor is feasible. It may optimize intraoperative antinociception and improve postoperative comfort.     

Comparação entre a posição de rampa e posição olfativa durante intubação traqueal: revisão sistemática e meta‐análise

ObjectivesPositioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position.MethodsPubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack‐Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers and complications during ETI.ResultsSeven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta‐analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence.ConclusionOur meta‐analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large‐scale well‐designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.     

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.

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.

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.     

Paralisia de cordas vocais após intubação endotraqueal: uma complicação incomum da anestesia geral

Background

General anesthesia is a safe, frequent procedure in clinical practice. Although it is very unusual in procedures not related to head and or neck surgery, vocal cord paralysis is a serious and important complication. Incidence has been associated with patient age and comorbidities, as well as the position of the endotracheal tube and cuff. It can become a dangerous scenario because it predisposes aspiration.

Vasculite testicular – uma manifestação rara de artrite reumatoide

Testicular vasculitis is a very rare extra-articular manifestation of rheumatoid arthritis (RA). We describe the case of a 53-year-old man diagnosed with RA for eight years, who was poorly controlled and developed rheumatoid vasculitis, which manifested as leg ulcers and peripheral polyneuropathy. The patient also had acute neutrophilic meningitis and was treated with antibiotics and intravenous pulse therapy with methylprednisolone (500 mg daily) for three days, followed by oral cyclophosphamide (2 mg/kg daily) and prednisone. Overall improvement was observed, and the patient was discharged. But 15 days later, the meningitis recurred, and the patient was readmitted and treated again with antibiotics. Three days later, he developed pain and enlargement of his left testicle with gangrene. Unilateral orchiectomy was performed, revealing lymphocytic vasculitis. The patient died two days later due to aspiration pneumonia. This case illustrates a rare and severe manifestation of rheumatoid vasculitis.     

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.     

Efeitos dos anestésicos locais na cicatrização de feridas

Introduction

Local anesthetic infiltration is used widely for post‐operative analgesia in many situations. However the effects of local anesthetics on wound healing are not demonstrated clearly. This study planned to evaluate the effects of lidocaine, prilocaine, bupivacaine and levobupivacaine on wound healing, primarily on wound tensile strength and on collagen ultrastructure.

Monitoração da coagulação pela tromboelastometria no intraoperatório de transplante hepático em um paciente usando varfarina – relato de caso

Introduction

Advanced hepatic disease may – in addition to the widely recognized hemorrhagic complications – occur with thrombotic events. We describe the case of a cirrhotic patient taking warfarin and whose coagulation management during liver transplantation was guided by thromboelastometry (ROTEM^®).

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.

Comparação entre o laser de baixa potência,ultrassom terapêutico e associação,na dor articular em ratos Wistar

IntroductionBoth therapeutic ultrasound as a low level laser therapy are used to control musculoskeletal pain, despite controversy about its effects, yet the literature is poor and also presents conflicting results on possible cumulative effects of techniques association. The aim was to compare the antinociceptive effects of low level laser therapy, therapeutic ultrasound and the association.Methods24 Wistar rats were divided into: GPL – induction of hyperesthesia in the right knee, and untreated; GUS – treated with therapeutic ultrasound (1 MHz, 0.4 W/cm²) GL – low intensity laser (830 nm, 8 J/cm²); GL+US – treated with both techniques. To produce the hyperesthesia 100 μl of 5% formalin solution were injected into the tibiofemoral joint space, which was assessed by von Frey filament digital before (EV1), 15 (EV2), 30 (EV3) and 60 (EV4) minutes after induction.ResultsIn comparison within groups, for the withdrawal threshold when the filament was applied to the knee, the back to baseline was observed only for GUS. Comparisons between groups were not different in EV3, and GL was higher than GPL. In EV4 the three groups effectively treated were higher than placebo. On withdrawal threshold on the plantar surface, GL showed return to baseline values already in EV3, and GUS and GL+US returned in EV4. Comparing the groups in EV3 there was a significantly lower threshold to compare GPL with GL and GUS (p <0.05), and there was only EV4 differences when comparing GPL with GUS.ConclusionBoth modalities showed antinociceptive effects.     

Sedação com dexmedetomidina e remifentanil em anestesia local para monitoração intraoperatória da fala: um relato de caso

Background and objective

Some surgical procedures such as laryngoplasty require patients to remain conscious during the intraoperative phase in order to enable speech monitoring. Dexmedetomidine and remifentanil were used in this study, since they promote appropriate patient collaboration with facilitated awakening, and are rapidly eliminated.

Tamponamento cardíaco: uma complicação rara da cateterização venosa central – relato de um caso clínico

The extensive use of central venous catheters (CVC) in a hospital environment leads to increased iatrogenic complications, as more catheters are used enclosed and its maintenance is prolonged. Several complications are known to be related to central venous catheter, of which the uncommon cardiac tamponade (CT), hardly recognized and associated with high mortality.We present a clinical case, with favorable outcome, of a patient who developed a CT 17 days after CVC placement, and try to reflect on the measures that can be taken to reduce its incidence, as well as the therapeutic approaches to practice in the presence of a suspected CT.     

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.     

Correção endovascular de lesão de artéria subclávia secundária à cateterismo de veia jugular interna: relato de caso

Background and objectivesUltrasound‐guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life‐threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.Case reportWe describe a case of the successful endovascular repair of right subclavian artery injury in a 75‐year‐old woman. Subclavian artery was injured secondary to ultrasound‐guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.ConclusionUnder general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.