Tromboelastometria rotacional na avaliação dos efeitos de cristaloides balanceados,hidroxietilamido e gelatina na coagulação: estudo randômico

Background and objectivesModern crystalloid and colloid solutions are balanced solutions which are increasingly used in perioperative period. However, studies investigating their negative effect on whole blood coagulation are missing, and vivid debate is going on about which solution has the minimal coagulopathy effect. The aim of our study was to assess the effect of modern fluid solutions on whole blood coagulation using rotational thromboelastometry.MethodsBlood samples were obtained from 30 patients during knee arthroscopy before and after administration of 500 mL of crystalloid, Hydroxyethyl Starch and gelatin according to the randomization. Rotational thromboelastometry (Extem, Intem and Fibtem tests) was used to assess negative effect of fluid solutions on whole blood coagulation.ResultsIn Extem test, the initiation phase of fibrin clot formation represented by CT parameter was not influenced by any fluid solution (p > 0.05). The speed of clot formation represented by CFT and α angle was impaired by Hydroxyethyl Starch and gelatin but not by crystalloids (p < 0.05). The strength of formatted coagulum represented by MCF parameter was impaired both in Extem and Fibtem test by HES and in Fibtem also by crystalloids (p < 0.05). Intem test was not negatively influenced by any crystalloid or colloid solution in any parameter (p > 0.05).ConclusionExtem test appears to be sensitive to coagulopathy effect of modern colloids and crystalloids. Hydroxyethyl starch has the most obvious negative effect on clot formation followed by gelatin and finally by crystalloids. Intem test seems to be insensitive to adverse effect of modern colloids and crystalloids.     

Efeito de duas doses diferentes de dexmedetomidina na incidência de agitação ao despertar após cirurgia para correção de estrabismo: um ensaio clínico randômico

Background and objective

Emergence agitation is a postoperative negative behavior that affects mainly children. We studied the effect of two different doses of dexmedetomidine on the incidence and degree of EA in children undergoing strabismus surgery.

Efeitos antimicrobianos do fentanil e da bupivacaína: estudo in vitro

Study objectiveIn this study, we aimed to compare the antimicrobial effects of bupivacaine and fentanyl citrate and to reveal the impact on antimicrobial effect potential in the case of combined use.DesignIn vitro prospective study.SettingUniversity Clinical Microbiology Laboratory.MeasurementsIn our study, in vitro antimicrobial effect of 0.05 mg.mL^‐1 fentanyl citrate, 5 mg.mL^‐1 bupivacaine were tested against Staphylococcus aureus American Type Culture Collection (ATCC) 29213, Pseudomonas aeruginosa ATCC 27853, Klebsiella pneumoniae ATCC 13883, Escherichia coli ATCC 25922 and Candida albicans ATCC 10231 as Group F (Fentanyl Citrate) and Group B (Bupivacaine), respectively. S. aureus ATCC 29213, P. aeruginosa ATCC 27853, Klebsiella pneumoniae ATCC 13883 and Escherichia coli ATCC 25922 were cultured onto Mueller Hinton agar (Oxoid, UK) plates and Candida albicans ATCC 10231 were cultured onto Sabouraud dextrose agar (Oxoid, UK) plates for 18‐24 hours at 37 °C.Main resultsIn terms of inhibition zone diameters, S. Aureus ATCC 29213, P. aeruginosa ATCC 27853, and C. albicans ATCC10231 values obtained after 12 and 24 hours of incubation were significantly higher in Group F than Group B (p < 0.001). In terms of inhibition zone diameters, E. coli ATCC 25922, and K. pneumomiae ATCC 13883 values obtained after 12 and 24 hours of incubation were significantly higher in Group B than Group F (p < 0.001, E. coli 12ª hour p = 0.005).ConclusionsAddition of fentanyl to Local Anesthetics (LAs) is often preferred in regional anesthesia applications in today's practice owing especially to its effect on decreasing the local anesthetic dose and increasing analgesia quality and patient satisfaction. However, when the fact that fentanyl antagonized the antimicrobial effects of LAs in the studies is taken into account, it might be though that it contributes to an increase in infection complications. When the fact that fentanyl citrate, which was used in our study and included hydrochloric acid and sodium hydroxide as protective agents, broadened the antimicrobial effect spectrum of LAs, had no antagonistic effect and showed a synergistic antimicrobial effect against E. Coli is considered, we are of the opinion that the addition of fentanyl to LAs would contribute significantly in preventing the increasing regional anesthesia infection complications.     

Comparação das ventilações controlada por volume e controlada por pressão na mecânica respiratória em cirurgia bariátrica laparoscópica: estudo clínico randômico

BackgroundIt is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.ObjectivesTo compare volume‐controlled ventilation and pressure‐controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.MethodsSixty‐two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume‐controlled ventilation and pressure‐controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5 minutes after induction, 30 minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar‐arterial oxygen gradient pressure were calculated.ResultsPeak airway pressures were lower in patients ventilated in pressure‐controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.ConclusionsPressure‐controlled ventilation mode is not superior to volume‐controlled ventilation mode in patients with laparoscopic bariatric surgery.     

Cetamina como adjuvante de bupivacaína em bloqueio do nervo infraorbitário para analgesia após correção de lábio leporino

Objectives

We conducted this study to investigate the safety and analgesic efficacy of the addition of Ketamine to Bupivacaine in bilateral extra‐oral infra‐orbital nerve block in children undergoing cleft lip surgeries.

Comparação do bloqueio do canal adutor para analgesia em cirurgia artroscópica com ropivacaína isolada e ropivacaína + clonidina

Background and objectivesInadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound‐guided adductor canal block with ropivacaine alone and ropivacaine with clonidine.MethodsA prospective randomized double blinded study was conducted including sixty‐three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S – control group received adductor canal block with 30 mL saline, Group R – ropivacaine group received adductor canal block with 30 mL of 0.375% ropivacaine and Group RC – clonidine group received adductor canal block with 30 mL of 0.375% ropivacaine with clonidine 1 μg.kg⁻¹. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting.ResultsThe mean pain free periods were 20 min, 384.76 min and 558.09 min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement.ConclusionAddition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.     

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.

Comparação dos efeitos de sulfato de magnésio e da dexmedetomidina sobre a qualidade da visibilidade em cirurgia endoscópica sinusal: estudo clínico randomizado

Background and objectivesEven a small amount of bleeding during endoscopic sinus surgery can corrupt the endoscopic field and complicate the procedure. Various techniques, including induced hypotension, can minimize bleeding during endoscopic sinus surgery. The aim of this study was to compare the surgical vision quality, haemodynamic parameters, postoperative pain, and other effects of magnesium, a hypotensive agent, with that of dexmedetomidine, which was initially developed for short‐term sedation in the intensive care unit but also is an alpha 2 agonist sedative.Method60 patients between the ages of 18 and 45 years were divided into either the magnesium group (Group M) or the dexmedetomidine group (Group D). In Group M, magnesium sulphate was given at a pre‐induction loading dose of 50 mg kg⁻¹ over 10 min and maintained at 15 mg kg⁻¹ h⁻¹; in Group D, dexmedetomidine was given at 1 mcg kg⁻¹ 10 min before induction and maintained at 0.6 mcg kg⁻¹ h⁻¹. Intraoperatively, the haemodynamic and respiratory parameters and 6‐point intraoperative surgical field evaluation scale were recorded. During the postoperative period, an 11‐point numerical pain scale, the Ramsay sedation scale, the nausea/vomiting scale, the adverse effects profile, and itching parameters were noted.ResultsGroup D showed a significant decrease in intraoperative surgical field evaluation scale scale score and heart rate. The average operation time was 50 min, and Group M had a higher number of prolonged surgeries. No significant difference was found in the other parameters.ConclusionsDue to its reduction of bleeding and heart rate in endoscopic sinus surgery and its positive impacts on the duration of surgery, we consider dexmedetomidine to be a good alternative to magnesium.     

Anestesia em cirurgia para correção de pentalogia de Cantrell: relato de caso

Pentalogy of Cantrell is a congenital anomaly associated with defects in the abdominal wall, sternum, diaphragm, and diaphragmatic pericardium formation, in addition to the development of cardiac abnormalities. It is a rare disease with an estimated incidence of one case for every 65,000 births, being more common in males (60% of cases). It has a reserved prognosis with mortality around 63%, and a maximum of 9 months survival after surgery. There are few case reports addressing the pentalogy of Cantrell, which is justified by the rarity of this pathology. In this report our objective was to describe a surgical case of a female patient and make some anesthetic considerations about this rare congenital malformation.     

Comparação de diferentes testes para determinar intubação difícil em pacientes pediátricos

BackgroundThe difficulties with airway management is the main reason for pediatric anesthesia‐related morbidity and mortality.ObjectiveTo assess the value of modified Mallampati test, Upper‐Lip‐Bite test, thyromental distance and the ratio of height to thyromental distance to predict difficult intubation in pediatric patients.DesignProspective analysis.Measurements and resultsData were collected from 5 to 11 years old 250 pediatric patients requiring tracheal intubation. The Cormack and Lehane classification was used to evaluate difficult laryngoscopy. Sensitivity, specificity, positive predictive value and AUC values for each test were measured.ResultsThe sensitivity and specificity of modified Mallampati test were 76.92% and 95.54%, while those for ULBT were 69.23% and 97.32%. The optimal cutoff point for the ratio of height to thyromental distance and thyromental distance for predicting difficult laryngoscopy was 23.5 (sensitivity, 57.69%; specificity, 86.61%) and 5.5 cm (sensitivity, 61.54%; specificity, 99.11%). The modified Mallampati was the most sensitive of the tests. The ratio of height to thyromental distance was the least sensitive test.ConclusionThese results suggested that the modified Mallampati and Upper‐Lip‐Bite tests may be useful in pediatric patients for predicting difficult intubation.     

Comparação de videolaringoscópio com canal e máscara laríngea na intubação traqueal de pacientes obesos: estudo clínico randomizado

BackgroundObesity causes various difficulties in intubation and ventilation, which are confronted due to increased fat tissue in the upper airway and diminished compliance in the chest wall. Videolaryngoscopes and Intubating Laryngeal Mask Airway (ILMA) are good options as recommended by the American Society of Anesthesologists (ASA) difficult airway guidelines. We aimed to compare ILMA and Airtraq (a channeled videolaryngoscope) in obese patients.MethodsEighty patients with ASA physical status I‐III, aged between 18 and 65 years and with a body mass index greater than 35 kg.m^‐2, who were undergoing elective surgery requiring orotracheal intubation, were included in the study. Patients were intubated with one of the devices cited.ResultsThere was no difference between the number of intubation attempts, insertion times and need for optimisation manoeuvres of Airtraq and ILMA. The intubation with Airtraq was accomplished in a shorter period of time than in that in the ILMA group (29.9 ± 22.1 s vs. 50.7 ± 21.2 s; p < 0.001). A significant difference was found when the times of total intubation were compared (29.9 ± 22.1 s vs. 97.4 ± 42.7 s; p < 0.001). The mean arterial pressure statistically increased after device insertion in the ILMA group (p < 0.05).ConclusionsAirtraq appears to be superior to ILMA in obese patients, with a total of time intubation of less than 60 seconds and with low mean arterial pressure changes. However, ILMA is still a useful tool that provides both ventilation and intubation throughout the whole intubation process.     

Midríase unilateral: uma complicação da cirurgia de coluna em decúbito ventral

Prone position is commonly used for better access to surgical site, but may be associated with a variety of complications. Perioperative Visual Disturbances or loss is rare but a devastating complication that is primarily associated with spine surgeries in prone position. In this case we report a 42 year old ASA‐II patient who developed anisocoria with left pupillary dilatation following lumbar microdiscectomy in prone position. Following further evaluation of the patient, segmental pupillary palsy of the left pupillary muscles was found to be the possible because of anisocoria. Anisocoria partially improved but persisted till follow up.     

Correlação entre saturação venosa central de oxigênio perioperatória e mortalidade em cirurgia cardíaca: estudo prospectivo observacional

BackgroundCardiac surgery can produce persistent deficit in the ratio of Oxygen Delivery (DO₂) to Oxygen Consumption (VO₂). Central venous oxygen Saturation (ScvO₂) is an accessible and indirect measure of DO₂/VO₂ ratio.ObjectiveTo monitor perioperative ScvO₂ and assess its correlation with mortality during cardiac surgery.MethodsThis prospective observational study evaluated 273 patients undergoing cardiac surgery. Blood gas samples were collected to measure ScvO₂ at three time points: T0 (after anesthetic induction), T1 (end of surgery), and T2 (24 hours after surgery). The patients were divided into two groups (survivors and nonsurvivors). The following outcomes were analyzed: intrahospital mortality, length of Intensive Care Unit (ICU) and hospital stay (LOS), and variation in ScvO₂.ResultsOf the 273 patients, 251 (92%) survived and 22 (8%) did not. There was a significant perioperative reduction of ScvO₂ in both survivors (T0 = 78% ± 8.1%, T1 = 75.4% ± 7.5%, and T2 = 68.5% ± 9%; p < 0.001) and nonsurvivors (T0 = 74.4% ± 8.7%, T1 = 75.4% ± 7.7%, and T2 = 66.7% ± 13.1%; p < 0.001). At T0, the percentage of patients with ScvO₂ < 70% was greater in the nonsurvivor group (31.8% vs. 13.1%; p = 0.046) and the multiple logistic regression showed that ScvO₂ is an independent risk factor associated with death, OR = 2.94 (95% CI 1.10 − 7.89) (p = 0.032). The length of ICU and LOS were 3.6 ± 3.1 and 7.4 ± 6.0 days respectively and was not significantly associated with ScvO₂.ConclusionsEarly intraoperative ScvO₂ < 70% indicated a higher risk of death. A perioperative reduction of ScvO₂ was observed in patients undergoing cardiac surgery, with high intraoperative and lower postoperative levels.     

Os efeitos condrotóxicos e apoptóticos de levobupivacaína e bupivacaína na articulação do joelho de coelhos

Background

A single dose injection or continuous infusion of local anesthetics into the joint space is considered to be a well‐defined analgesia technique. The aim of this study was to investigate the chondrotoxic and apoptotic effects of single‐dose intra‐articular injection of levobupivacaine and bupivacaine on rabbit knee joint tissues.

Estudo prospectivo randômico,duplo‐cego e controlado comparando tramadol,clonidina e dexmedetomidina para tremores pós‐raquianestesia

Introduction

Shivering, a common intraoperative problem under spinal anesthesia increases the oxygen consumption considerably and is uncomfortable and distressing to the patient, anesthesiologist as well as surgeon. The present study was designed to explore the effectiveness of tramadol, clonidine and dexmedetomidine in the treatment of post spinal anesthesia shivering and to look for their adverse effects.

Remifentanil–cetamina vs. propofol–cetamina para sedação em pacientes pediátricos submetidos à colonoscopia: ensaio clínico randômico

Background and objectives

Pediatric patients frequently require deep sedation or general anesthesia for colonoscopy. This study was designed to compare the sedative efficacy of remifentanil–ketamine combination with propofol–ketamine combination in children undergoing colonoscopy.

Uso preventivo de cetamina nebulizada para controle da dor após amigdalectomia em crianças: estudo randômico e controlado

ObjectivesThe administration of ketamine as nebulized inhalation is relatively new and studies on nebulized ketamine are scarce. We aimed to investigate the analgesic efficacy of nebulized ketamine (1 and 2 mg.kg^?1) administered 30 min before general anesthesia in children undergoing elective tonsillectomy in comparison with intravenous ketamine (0.5 mg.kg^?1) and saline placebo.MethodsOne hundred children aged (7‐12) years were randomly allocated in four groups (n = 25) receive; Saline Placebo (Group C), Intravenous Ketamine 0.5 mg.kg^?1 (Group K‐IV), Nebulized Ketamine 1 mg.kg^?1 (Group K‐N1) or 2 mg.kg^?1 (Group K‐N2). The primary endpoint was the total consumption of rescue analgesics in the first 24 h postoperative.ResultsThe mean time to first request for rescue analgesics was prolonged in K‐N1 (400.9 ± 60.5 min, 95% CI 375.9‐425.87) and K‐N2 (455.5 ± 44.6 min, 95% CI 437.1‐473.9) groups compared with Group K‐IV (318.5 ± 86.1 min, 95% CI 282.9‐354.1) and Group C (68.3 ± 21.9 min, 95% CI 59.5‐77.1; p < 0.001), with a significant difference between K‐N1 and K‐N2 Groups (p < 0.001). The total consumption of IV paracetamol in the first 24 h postoperative was reduced in Group K‐IV (672.6 ± 272.8 mg, 95% CI 559.9‐785.2), Group K‐N1 (715.6 ± 103.2 mg, 95% CI 590.4‐840.8) and Group K‐N2 (696.6 ± 133.3 mg, 95% CI 558.8‐834.4) compared with Control Group (1153.8 ± 312.4 mg, 95% CI 1024.8‐1282.8; p < 0.001). With no difference between intravenous and Nebulized Ketamine Groups (p = 0.312). Patients in intravenous and Nebulized Ketamine Groups showed lower postoperative VRS scores compared with Group C (p < 0.001), no differences between K‐IV, K‐N1 or K‐N2 group and without significant adverse effects.ConclusionPreemptive nebulized ketamine was effective for post‐tonsillectomy pain relief. It can be considered as an effective alternative route to IV ketamine.     

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.     

Sufentanil durante a indução da anestesia intravenosa total à base de remifentanil: ensaio clínico randômico

BackgroundPostoperative pain represents an important concern when remifentanil is used for total intravenous anesthesia because of its ultrashort half‐life. Longer acting opioids, such as sufentanil, have been used during induction of remifentanil‐based total intravenous anesthesia as a means to overcome this shortcoming. However, the effectiveness and safety of such strategy still lacks evidence from randomized clinical trials. Hence, we aimed to assess the postoperative analgesic efficacy and safety of a single dose of sufentanil administered during the induction of remifentanil‐based total intravenous anesthesia.MethodsForty patients, scheduled for elective open abdominal surgery, were randomized to receive remifentanil‐based total intravenous anesthesia with or without a single dose of sufentanil upon induction. We assessed the postoperative morphine consumption administered through a patient‐controlled analgesia pump. Self‐reported pain scores and the occurrence of nausea, vomiting, pruritus, agitation, somnolence and respiratory depression were also assessed up to 2 days after surgery.ResultsThe mean difference between the sufentanil and control groups regarding morphine consumption in the post‐anesthetic care unit and at 12, 24 and 48 h after surgery were −7.2 mg (95%CI: −12.5 to −2.1, p < 0.001), −3.9 mg (95%CI: −11.9 to 4.7, p = 0.26), −0.6 mg (95%CI: (−12.7 to 12.7, p = 0.80), and −1.8 mg (95%CI: (−11.6 to 15.6, p = 0.94), respectively. Neither self‐reported pain nor the incidence of adverse events were significantly different between groups at any time point.ConclusionOur findings suggest that the administration of sufentanil during induction of remifentanil‐based total intravenous anesthesia is associated with decreased early postoperative opioid consumption.