Calcinose distrófica cutânea na doença venosa crônica de membros inferiores / Dystrophic calcinosis cutis in chronic venous disease of the lower limbs

Resumo As úlceras de membros inferiores, secundárias à doença venosa crônica (DVC), constituem um problema significativo de saúde pública no Brasil e representam cerca de 70% do total dessas úlceras. Apesar dos recentes avanços tecnológicos e das diversas opções terapêuticas utilizadas para essas lesões crônicas, existem diversos fatores que podem estar implicados na resistência ao tratamento. A calcificação distrófica cutânea (CDC) é uma condição rara e frequentemente subdiagnosticada, que, quando associada à DVC, pode estar associada à refratariedade no processo cicatricial. Neste artigo, relatamos um caso de CDC em paciente portador de DVC e discutimos a sua etiologia, fisiopatologia e possíveis opções de tratamento.

Abstract Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Escleroterapia con polidocanol en insuficiencia venosa superficial CEAP C1 / Sclerotherapy with polidocanol in superficial venous insufficiency CEAP C1

Insuficiencia venosa es definida como la patología que causa síntomas en los miembros inferiores, incluyendo edema, hiperpigmentación, lipodermatoesclerosis y ulceración e implica una anormalidad funcional del sistema venoso. Objetivo: Se compararon los resultados en cuanto a complicaciones y satisfacción reportada por las pacientes, con la Escleroterapia con Polidocanol utilizando aire y agua como diluyente. Métodos: Se incluyeron en el estudio a 60 pacientes del sexo femenino con diagnóstico de Insuficiencia Venosa Superficial CEAP C1, divididas en dos grupos, a las cuales se les aplicó Escleroterapia con Polidocanol mezclado con agua y aire. Se realizó seguimiento durante cuatro semanas donde se recogió la información del paciente con respecto a la mejoría de los síntomas antes de iniciar el tratamiento y los efectos adversos del Polidocanol con ambas terapias. Resultados: Dentro de las complicaciones de ambos tratamientos únicamente fue reportado el Matting en rango leve durante la primera semana. El único síntoma reportado como severo fue Dolor en la escleroterapia con polidocanol mezclado con aire. Los demás signos síntomas fueron reportados dentro del rango de moderado el cual descendió hasta leve entre la segunda y tercera semana, no encontrando reportes a la cuarta semana. La única complicación reportada fue el Matting en la escleroterapia con polidocanol mezclado con aire. Conclusión: No se encontraron diferencias significativas en grado de satisfacción con la eficacia del tratamiento, los efectos adversos, la forma en que se administra el medicamento entre ambos tratamientos de escleroterapia, oscilando los rangos de satisfacción entre el 43 al 70%. (AU)

Venous insufficiency is defined as the pathology that causes symptoms in the lower limbs, including edema, hyperpigmentation, lipodermatosclerosis and ulceration and implies a functional abnormality of the venous system. Objective: The results in terms of complications and satisfaction reported by the patients were compared with Sclerotherapy with Polidocanol using air and water as diluent. Methods: 60 female patients with a diagnosis of Superficial Venous Insufficiency CEAP C1 were included in the study, divided into two groups, to which Sclerotherapy with Polidocanol mixed with water and air was applied. A follow-up was carried out for four weeks where information from the patient was collected regarding the improvement of symptoms before starting treatment and the adverse effects of Polidocanol with both therapies. Results: Within the complications of both treatments, only Matting was reported in a mild range during the first week. The only symptom reported as severe was pain in sclerotherapy with polidocanol mixed with air. The other signs and symptoms were reported within the moderate range, which decreased to mild between the second and third week, finding no reports at the fourth week. The only complication reported was Matting in sclerotherapy with polidocanol mixed with air. Conclusion: No significant differences were found in the degree of satisfaction with the efficacy of the treatment, the adverse effects, the way in which the drug is administered between both sclerotherapy treatments, the satisfaction ranges ranging from 43 to 70%. (AU)

Avaliação da efetividade do uso de meias de compressão na prevenção do edema ocupacional em cabeleireiras / Evaluation of the effectiveness of wearing compression stockings for prevention of occupational edema in hairdressers

Resumo Contexto O edema ocupacional (EO) de membros inferiores (MMII) é um importante fator de queda na qualidade de vida, e a sua prevenção impõe a prescrição de medidas profiláticas, como o uso de meias de compressão (MCs). Objetivos Avaliar a efetividade das MCs na prevenção do EO e a sua repercussão na qualidade de vida de cabeleireiras. Métodos Este ensaio clínico realizou medidas de tornozelo e panturrilha de 38 cabeleireiras sem doença venosa no início e no final da jornada de trabalho em um momento sem e em outro usando MCs. Também responderam um questionário sobre sintomas e qualidade de vida em doença venosa. Resultados Os valores do ponto B foram de 21,1±2,2 cm no momento inicial sem meias, 22,1±2,3 cm no momento final sem meias (p = 0,0001 em relação ao inicial sem meias), e 21,2±2,1 cm no momento final com meias (p = 0,0001 em relação ao final sem meias). Não foi significante a diferença entre os valores médios do ponto B inicial sem meias e final com meias (p=0,324), ou seja, não houve formação de edema nos MMII ao final da jornada de trabalho em ortostatismo prolongado quando em uso de MCs. Pôde-se observar melhora da limitação sobre as atividades laborais (p = 0,0001), domésticas (p = 0,008) e de lazer ou sociais em pé (p = 0,0001). Conclusões As MCs são efetivas na prevenção do EO de MMII, e a atenuação de sintomas como dor e fadiga contribui diretamente para melhor qualidade de vida de cabeleireiras.

Abstract Background Occupational lower limb edema is an important factor in deterioration of quality of life. Prevention involves prescription of prophylactic measures, such as wearing compression stockings. Objectives To evaluate the effectiveness of compression stocking for prevention of occupational edema and its repercussions for the quality of life of hairdressers. Methods A clinical trial involving measurements of the ankles (point B) and calves (Point C) of 38 hairdressers without venous disease at the beginning and end of workdays spent wearing or not wearing compression stockings. Participants also answered a questionnaire about symptoms and quality of life in venous disease. Results Point B measurements were: 21.1 ± 2.2 cm in the morning without stockings; 22.1 ± 2.3 cm at the end of the day without stockings (p = 0.0001 compared to baseline without stockings); and 21.2 ± 2.1 cm at the end of the day wearing compression stockings (p = 0.0001 compared to the end of day not wearing compression stockings). The comparison between point B values for the start of the day without compression stockings and the end of the day with stockings (p = 0.324) was not significant, showing that there was no lower limb edema at the end of the working day when compression stockings were worn. Improvements were observed in ratings for limitations of work activities (p = 0.0001), domestic activities (p = 0.008) and leisure or social activities performed standing up(p = 0.0001). Conclusions Compression stockings are effective for preventing occupational lower limb edema and the attenuation of symptoms such as pain and fatigue directly contributes to better quality of life for hairdressers.

Experiencia de la angioplastía en miembros inferiores en la enfermedad arterial periférica en una clínica privada en el sur de Colombia / Experience of angioplasty in lower limbs in peripheral arterial disease in a private clinic in southern Colombia

OBJETIVO: Evaluar las características de los pacientes sometidos a angioplastía en miembros inferiores, así como establecer posibles asociaciones entre los factores que lleven a complicaciones de la misma. MATERIALES Y MÉTODO: Estudio descriptivo, observacional, retrospectivo de corte transversal durante 18 meses en el que se evaluaron aquellos pacientes con enfermedad arterial periférica sometidos a angioplastía de miembros inferiores, sus características demográficas, clínicas, quirúrgicas y las complicaciones postoperatorias. RESULTADOS: Se evaluaron 158 registros de pacientes con edades entre 30 y 95 años. El 65,2% (n = 103) de los procedimientos se realizaron de forma electiva, los vasos intervenidos con mayor frecuencia fueron la arteria femoral superficial (64%), el tipo de intervención endovascular más frecuente fue la combinación de balón + balón medicado (32,9%), el tratamiento farmacológico postoperatorio más usado fue la combinación de ácido acetilsalicílico (ASA) y clopidogrel (86,1%). Se presentaron 21 casos de complicaciones, la más frecuente fue la amputación menor (52%). Se encontró mayor riesgo de amputación menor cuando el procedimiento quirúrgico es realizado de forma urgente (p = 0,012; OR [IC 95%]: 4,8 [1,4-16,5]). DISCUSIÓN: La complicación posangioplastía con diferencia estadísticamente significativa fue la amputación menor cuando el procedimiento se realizó de manera urgente, esta asociación pudo estar relacionada con el estado clínico del paciente en el momento del ingreso y no con el procedimiento quirúrgico. CONCLUSIÓN: La angioplastía realizada de urgencias fue un procedimiento tan seguro como cuando se realiza de forma programada, dado por la misma proporción de sangrado o disección arterial.

AIM: Evaluate the characteristics of patients undergoing angioplasty in the lower limbs, as well as to establish possible associations between the factors leading to complications. MATERIALS AND METHODS: Observational descriptive, cross-sectional and retrospective study conducted during 18 months in which patients with peripheral arterial disease undergoing angioplasty of the lower limb were included, as well their demographic, clinical, and surgical characteristics and the postoperative complications. RESULTS: 158 records of patients between 30 and 95 years were evaluated. 65.2% (n = 103) of the procedures were performed not urgently, the most frequently intervened vessels were the superficial femoral artery (64%), the most frequent type of endovascular intervention was the combination of balloon + medicated ball (32.9%), the most used postoperative pharmacological treatment was the combination of acetylsalicylic acid (ASA) and clopidogrel (86.1%). There were 21 cases of complications, the most frequent complication was minor amputation (52%). A higher risk of minor amputation was found when the surgical procedure was performed urgently (p = 0.012, OR [95% CI]: 4.8 [1.4-16.5]). DISCUSION: The post-angioplasty complication with statistically significant difference was minor amputation when the procedure was performed urgently, this association was related to the clinical status of the patient at the time of admission and not to the surgical procedure. CONCLUSION: Angioplasty performed urgently is as safe as elective procedures, given by the same proportion of bleeding or arterial dissection.

Curativo com filme e gel de biopolímero de celulose bacteriana no tratamento de feridas isquêmicas após revascularização de membros inferiores / Bacterial cellulose biopolymer film and gel dressing for the treatment of ischemic wounds after lower limb revascularization

RESUMO Objetivo: avaliar o uso do curativo de filme e gel de biopolímero de celulose bacteriana no tratamento de pacientes com feridas isquêmicas submetidos à revascularização dos membros inferiores. Métodos: ensaio clínico randomizado realizado no ambulatório de Angiologia e Cirurgia Vascular do Hospital das Clínicas da Universidade Federal de Pernambuco, entre janeiro de 2017 e dezembro de 2018. Foram acompanhados 24 pacientes após revascularização de membros inferiores, divididos em dois grupos: Experimental, tratado com filme e gel de biopolímero de celulose bacteriana, e Controle, tratado com ácidos graxos essenciais. Os pacientes foram acompanhados em consultas semanais para troca dos curativos e o processo de cicatrização das feridas foi avaliado em um período de 90 dias. Resultados: a redução da área das feridas isquêmicas no período de 30 dias foi de 4,3cm2 (55%), em média, para o grupo experimental, e de 5,5cm2 (48,5%) para o grupo controle (p>0,05). A taxa de cicatrização completa, em 90 dias, foi de 34,8%, sendo 50% no grupo experimental e 18,2% no grupo controle (p=0,053). Conclusão: o filme de biopolímero de celulose bacteriana associada a gel pode ser utilizado como curativo no tratamento de feridas isquêmicas de pacientes submetidos à revascularização de membros inferiores

ABSTRACT Objective: to evaluate the use of a bacterial cellulose biopolymer film and gel dressing in the treatment of patients with ischemic wounds submitted to lower limb revascularization. Methods: we conducted a randomized clinical trial in the Angiology and Vascular Surgery outpatient clinic of the Clinics Hospital of the Federal University of Pernambuco, between January 2017 and December 2018. We followed 24 patients after lower limb revascularization, divided into two groups: Experimental, treated with bacterial cellulose biopolymer film and gel, and Control, treated with essential fatty acids. Patients attended weekly appointments to change dressings and had their wound healing processes evaluated over a period of 90 days. Results: the reduction of the ischemic wounds' areas after 30 days was 4.3cm2 (55%) on average for the experimental group, and the 5.5cm2 (48.5%) for the control group (p>0.05). The complete healing rate at 90 days was 34.8%, 50% in the experimental group and 18.2% in the control group (p=0.053). Conclusion: the bacterial cellulose biopolymer film associated with gel can be used as a dressing in the treatment of ischemic wounds of patients undergoing revascularization of the lower limbs.

Carotid intima-media thickness and plaques in internal carotid artery as surrogate markers of lower limb arterial lesions in Chinese patients with diabetic foot

Peripheral arterial disease (PAD) can impair healing of diabetic foot (DF) in patients with diabetes mellitus. To determine whether carotid intima-media thickness (CIMT) can predict lower limb arterial lesions in patients with DF, this cross-sectional study enrolled patients with DF at West China Hospital (China) between January 2012 and December 2015. Ultrasonography was used to measure CIMT, assess the internal carotid arteries (ICA) for plaques, and evaluate lower limb segmental arteries for stenosis. The optimal CIMT cutoff for detecting lower limb PAD was determined by receiver operating characteristic (ROC) curve analysis. Factors associated with PAD were identified by logistic regression analyses. A total of 167 patients (mean age: 69.7±10.3 years; 102 men) were included. Patients with PAD were older and had higher levels of total cholesterol and low-density lipoprotein than patients without PAD (P<0.05). The area under the ROC curve was 0.747 (P<0.001). At the optimal CIMT cutoff of 0.71 mm, the sensitivity, specificity, positive predictive value, and negative predictive value were 79.65, 61.11, 81.08, and 58.93%, respectively. Compared with those without PAD, more patients with PAD had CIMT ≥0.71 mm (79.65 vs 38.89%; P<0.001) and ICA plaques (66.37vs 11.11%; P<0.001). Multivariate logistic regression revealed that age (odds ratio [OR]: 1.118; 95% confidence interval [95%CI]: 1.056-1.183; P<0.001), ICA plaques (OR: 13.452; 95%CI: 4.450-40.662; P<0.001), and CIMT ≥0.71 mm (OR: 2.802; 95%CI: 1.092-7.188; P=0.032) were associated with PAD.CIMT may be a surrogate marker of PAD in patients with DF.

Caracteristicas y frecuencia del personal de enfermeria que presenta varices, en servicios de hospitales publicos de Corrientes, Capital / Charactristics and frecuency of nursing staff presenting varicose veins, in public hospital service of Corrientes, Capital

Se realizó el estudio, para determinar lascaracterísticas del personal de Enfermería que presenta Várices en los servicios Emergencia,Terapia Intensiva y Clínica Médica de los hospitales "José Francisco de San Martin"y "Juan Pablo II" . El diseño metodológico utilizadofue de tipo cuantitativo, descriptivo,transversal y observacional.Del total de 150 profesionales que reunieron los criterios de inclusión, exclusión y eliminación,se selecionó a 54 enfermeros;por un muestreo probabilistico sistemático, la recolección de los datos se realizó durante los meses de agosto y septiembre del 2017, a travez de unaencuesta.Se analizaron las variables frecuencia de aparcición de Várices, edad, sexo, tipo de varices, antigüedad en el servicio, tiempo de bipedestacion...

The study was carried out to determine the characteristics of the nursing staff that presents varicose veins in the Emergency, Intensive Care and Medical Clinic services of the "José Francisco de San Martin" and "Juan Pablo II" hospitals. The methodological design used was quantitative, descriptive, prospective, crosssectional and observational. Out of the total of 150 professionals who met the inclusion, exclusion and elimination criteria, 54 nurses were selected, and by a systematic probabilistic sampling, the data collection was carried out during the months of August and September of 2017, through a survey. The variables of varices frequency, age, sex, type of varicose veins, length of service, and standing time were analyzed...

Acetaminophen mitigates myocardial injury induced by lower extremity ischemia-reperfusion in rat model

Abstract Objective: The injury-reducing effect of acetaminophen, an effective analgesic and antipyretic on ischemia-reperfusion continues to attract great attention. This study analyzed the protective effect of acetaminophen on myocardial injury induced by ischemia-reperfusion in an experimental animal model from lower extremity ischemia-reperfusion. Methods: Twenty-four Sprague-Dawley female rats were randomized into three groups (n=8) as (i) control group (only laparotomy), (ii) aortic ischemia-reperfusion group (60 min of ischemia and 120 min of reperfusion) and (iii) ischemia-reperfusion + acetaminophen group (15 mg/kg/h intravenous acetaminophen infusion starting 15 minutes before the end of the ischemic period and lasting till the end of the reperfusion period). Sternotomy was performed in all groups at the end of the reperfusion period and the heart was removed for histopathological examination. The removed hearts were histopathologically investigated for myocytolysis, polymorphonuclear leukocyte (PMNL) infiltration, myofibrillar edema and focal hemorrhage. Results: The results of histopathological examination showed that acetaminophen was detected to particularly diminish focal hemorrhage and myofibrillar edema in the ischemia-reperfusion + acetaminophen group (P<0.001, P=0.011), while there were no effects on myocytolysis and PMNL infiltration between the groups (P=1.000, P=0.124). Conclusion: Acetaminophen is considered to have cardioprotective effect in rats, by reducing myocardial injury induced by abdominal aortic ischemia-reperfusion.

Effect of cilostazol in experimental model of degloving injuries in rat limbs

Abstract Purpose: To evaluate the effect of the cilostazol on the evolution of partially avulsed flaps, using experimental model of cutaneous degloving in rat limbs. Methods: A controlled and randomized experimental study was carried out in which the blood flow and the percentage of flap necrosis were evaluated. We compared the study group, which received cilostazol, and the control group, which received enteral saline solution in the postoperative period. The blood flow in the flap was evaluated through Laser Doppler flowmetry, and a planimetry using the IMAGE J® software was employed for the calculation of the area of necrosis. Results: Enteral administration of cilostazol was associated with a higher mean blood flow in all regions of the flap, with a statistically significant difference in the proximal and middle regions (p<0.001) and a lower percentage of necrotic area in the flap (p<0.001). Conclusion: Postoperative enteral administration of cilostazol increased blood flow and decreased the total area of necrosis of avulsed cutaneous flaps of rat limbs.

Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia / Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior

Abstract Background and objectives Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first-line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block. Case report A female patient, afro-descendant, 69 years old, ASA II, admitted to the algology service due to refractory ischemic pain in the lower limbs. The patient had undergone several surgical procedures and conservative treatments without success. Vascular surgery considered the case as out of therapeutic possibility, unless limb amputation. At that time, sympathectomy was indicated. After admission to the operating room, the patient was monitored, positioned and sedated. The blockade was performed with the aid of radioscopy, bilaterally, at L2-L3-L4 right and L3 left levels. On the right side, at each level cited, 3 mL of absolute alcohol with 0.25% bupivacaine were injected without vasoconstrictor, and on the left side only local anesthetic. The procedure was performed uneventfully. The patient was discharged with complete remission of the pain. Conclusion Neurolitic block of the lumbar sympathetic chain is an effective and safe treatment option for pain control in patients with critical limb ischemia patients in whom the only possible intervention would be limb amputation.

Resumo Justificativa/objetivos A simpatectomia é uma das terapêuticas usadas no tratamento dadoença arterial obstrutiva crônica (DAOP). Embora não seja considerada como estratégia de primeira linha, deve ser lembrada no manejo dos quadros de dor de difícil controle. Este caso clínico descreve a evolução de uma paciente portadora de DAOP inoperável que respondeu adequadamente ao bloqueio simpático lombar. Relato de caso Paciente do sexo feminino, parda, 69 anos, estado físico II, acompanhada no serviço de algologia devido a dor isquêmica refratária em membros inferiores. A paciente já havia sido submetida a diversas abordagens cirúrgicas e tratamentos conservadores, sem sucesso. A cirurgia vascular considerou o caso como fora de possibilidade terapêutica, a não ser amputação do membro. Nesse momento, foi indicada simpatectomia. Após admissão no centro cirúrgico, a paciente foi monitorada, posicionada e sedada. O bloqueio foi feito com auxílio da radioscopia, bilateralmente, nos níveis L2-L3-L4 à direita e L3 à esquerda. Do lado direito, em cada nível citado, foram injetados 3 mL de álcool absoluto com bupivacaína 0,25% sem vasoconstritor e do lado esquerdo somente o anestésico local. O procedimento foi feito sem intercorrências. A paciente recebeu alta com completa remissão da dor. Conclusão O bloqueio neurolítico da cadeia simpática lombar é uma opção de tratamento eficaz e segura para controle da dor em pacientes portadores de isquemia crítica, nos quais a única intervenção possível seria a amputação do membro.

Enfermedad arterial periférica de extremidades inferiores: diagnóstico y tratamiento / Peripheric arterial disease: diagnosis and treatment

La enfermedad arterial periférica (EAP) es la afectación de la circulación arterial especialmente a nivel de las extremidades inferiores. Su prevalencia aumenta con la edad. La mayoría de los afectados estarán asintomáticos, lo que supone un reto, ya que debemos hacer un esfuerzo activo para diagnosticarla. Al diagnosticar la EAP, debemos hacer entender a nuestros pacientes que el riesgo no es perder la extremidad, sino presentar complicaciones cardiovasculares mayores o incluso, la muerte. Debemos orientar al paciente para realizar un cambio en su estilo de vida y a la vez concientizar al médico de atención primaria para realizar prevención y diagnóstico precoz de la EAP para así evitar progresión de la enfermedad con consecuencias irreversibles(AU)

Peripheral arterial disease (PAD) is the involvement of the arterial circulation especially in the lower limbs. The prevalence of this pathology increases with age. The majority of those affected will be asymptomatic, which is a challenge, since we have to make an active effort to diagnose them. When diagnosing PAD, we must make our patients understand that the risk is not to lose the limb, but to suffer major cardiovascular complications or death. We must guide the patient to make a change in lifestyle and at the same time. raise awareness of the primary care physician to perform prevention or early diagnosis of PAD and thus prevent progression of the disease with irreversible consequences(AU)

Protocolo de aferição da pressão arterial em membros inferiores / Protocolo de medición de la presión arterial en los miembros inferiores / Protocol for blood pressure measurement in lower limbs

Objetivo relatar a experiência de construção de um procedimento operacional padrão sobre a técnica de verificação da pressão arterial em membros inferiores. Método estudo descritivo, tipo relato de experiência, que ocorreu durante o Estágio Supervisionado Curricular de Enfermagem em uma unidade de internação de um hospital localizado no interior do Rio Grande do Sul, em 2017. Resultados o procedimento operacional padrão foi desenvolvido entre os acadêmicos e as enfermeiras com o objetivo de uniformizar a execução da atividade de forma segura, incluindo os materiais necessários, posição do paciente e guia de ação. Conclusão a criação do procedimento operacional padrão pelos acadêmicos de Enfermagem possibilitou a construção de um protocolo com a técnica correta de aferição da pressão arterial em membros inferiores e contribuirá significativamente para a prática clínica.

Objetivo narrar la experiencia de construcción de un procedimiento operativo estándar sobre la técnica de verificación de la presión arterial en miembros inferiores. Método estudio descriptivo, de tipo relato de experiencia, realizado durante la Pasantía Curricular Supervisada de Enfermería en una unidad de internación de un hospital del interior de Rio Grande do Sul, en 2017. Resultados el procedimiento operativo estándar se desarrolló entre los estudiantes y las enfermeras con el objeto de uniformizar la ejecución de la actividad de manera segura, incluyéndose los materiales necesarios, posición del paciente y manual de aplicación. Conclusión la creación del procedimiento operativo estándar por parte de los estudiantes de Enfermería permitió la construcción de un protocolo con la técnica correcta de medición de la presión arterial en miembros inferiores, que contribuirá significativamente con la práctica clínica.

Objective to report the experience of building a standard operating procedure on the technique of checking blood pressure in the lower limbs. Method this is a descriptive study, using an experience report design, that took place during the Supervised Nursing Curricular Training Program in an inpatient unit of a hospital in the countryside of the state of Rio Grande do Sul in 2017. Results the standard operating procedure was developed among the undergraduate students and nurses to standardize safe activity performance, including the necessary materials, patient position, and action guide. Conclusion the creation of a standard operating procedure by nursing students allowed the construction of a protocol with the correct blood pressure measurement technique in the lower limbs, and will contribute significantly to clinical practice.

Catheter-directed thrombolysis for patients with acute lower extremity deep vein thrombosis: a meta-analysis / Trombólise dirigida por cateter para pacientes com trombose venosa profunda aguda das extremidades inferiores: uma metanálise / Trombólisis dirigida por catéter para pacientes con trombosis venosa profunda aguda en las extremidades inferiores: un metanálisis

ABSTRACT Objectives: To evaluate case series studies that quantitatively assess the effects of catheter-directed thrombolysis (CDT) and compare the efficacy of CDT and anticoagulation in patients with acute lower extremity deep vein thrombosis (DVT). Methods: Relevant databases, including PubMed, Embase, Cochrane, Ovid MEDLINE and Scopus, were searched through January 2017. The inclusion criteria were applied to select patients with acute lower extremity DVT treated with CDT or with anticoagulation. In the case series studies, the pooled estimates of efficacy outcomes for patency rate, complete lysis, rethrombosis and post-thrombotic syndrome (PTS) were calculated across the studies. In studies comparing CDT with anticoagulation, summary odds ratios (ORs) were calculated. Results: Twenty-five articles (six comparing CDT with anticoagulation and 19 case series) including 2254 patients met the eligibility criteria. In the case series studies, the pooled results were a patency rate of 0.87 (95% CI: 0.85-0.89), complete lysis 0.58 (95% CI: 0.40-0.75), rethrombosis 0.11 (95% CI: 0.06-0.17) and PTS 0.10 (95% CI: 0.08-0.12). Six studies comparing the efficacy outcomes of CDT and anticoagulation showed that CDT was associated with a reduction of PTS (OR 0.38, 95%CI 0.26-0.55, p<0.0001) and a higher patency rate (OR 4.76, 95%CI 2.14-10.56, p<0.0001). Conclusion: Acute lower extremity DVT patients receiving CDT were found to have a lower incidence of PTS and a higher incidence of patency rate. In our meta-analysis, CDT is shown to be an effective treatment for acute lower extremity DVT patients.

RESUMO Objetivos: Avaliar os estudos de séries de casos e avaliar quantitativamente os efeitos da trombólise dirigida por cateter (TDC) e comparar a eficácia entre TDC e anticoagulação nos pacientes com trombose venosa profunda aguda das extremidades inferiores (TVP) para tratamento futuro. Métodos: Foram pesquisadas as seguintes bases de dados relevantes: PubMed, Embase, Cochrane, Ovid MEDLINE e Scopus​. Os critérios de inclusão foram aplicados para pacientes selecionados com TVP aguda de extremidades inferiores tratados com TDC comparada a TDC com anticoagulação. Nos estudos de série de casos, as estimativas agrupadas de resultados de eficácia para a taxa de permeabilidade, lise completa, retrombose e síndrome pós-trombótica (SPT) foram calculadas em todos os estudos. Em estudos comparando TDC com anticoagulação, foi calculada a razão de chance de resumo (summary odds ratio - OR). Resultados: Vinte e cinco artigos (seis comparando TDC com anticoagulação e 19 séries de casos), incluindo 2.254 pacientes, preencheram os critérios de elegibilidade. Nos estudos da série de casos, os resultados agrupados foram: taxa de permeabilidade 0,87 (IC95%: 0,85-0,89), lise completa 0,58 (IC95%: 0,40-0,75), e retrombose 0,11 (IC95%: 0,06-0,17), SPT 0,10 (IC95%: 0,08-0,12). Seis estudos que compararam os resultados de eficácia entre TDC e anticoagulação mostraram que TDC foi associada à redução da SPT (OR 0,38; IC95%: 0,26-0,55; p<0,0001) e maior taxa de permeabilidade (OR 4,76; IC95%: 2,14-10,56; p<0,0001). Conclusão: Pacientes com TVP aguda de extremidades inferiores que recebem TDC estão associados a uma menor incidência de SPT e maior incidência de taxa de permeabilidade. Em nossa metanálise, TDC é um tratamento eficaz para pacientes com TVP aguda de extremidades inferiores.

RESUMEN Objetivos: Evaluar estudios de series de casos y evaluar cuantitativamente los efectos de la trombólisis dirigida por catéter (TDC) y comparar la eficacia entre la TDC y anticoagulación en pacientes con trombosis venosa profunda (TVP) aguda de las extremidades inferiores para el tratamiento futuro. Métodos: Se realizaron búsquedas en bases de datos relevantes, incluyendo PubMed, Embase, Cochrane, Ovid MEDLINE y Scopus hasta enero de 2017. Los criterios de inclusión se aplicaron a pacientes seleccionados con TVP aguda de extremidad inferior tratados con TDC o comparados con TDC y anticoagulación. En estudios de series de casos, las estimaciones agrupadas de los resultados de eficacia para la tasa de patencia, la lisis completa, la retrombosis y el síndrome postrombótico (SPT) se calcularon a través de los estudios. En estudios que compararon la TDC con la anticoagulación, se calculó el resumen de las razónes de posibilidades (RP). Resultados: 25 artículos (seis que comparan TDC con anticoagulación y 19 series de casos) que incluyeron 2254 pacientes qienes cumplieron los criterios de elegibilidad. En los estudios de series de casos, los resultados agrupados fueron: tasa de patencia 0,87 (IC 95%: 0,85; 0,89), lisis completa 0,58 (IC 95%: 0,40; 0,75), retrombosis 0,11 (IC 95%: 0,06; 17,0), SPT 0,10 (IC 95%: 0,08; 0,12). Seis estudios que compararon los resultados de eficacia entre la TDC y anticoagulación mostraron que la TDC se asoció con una reducción de SPT (RP 0,38; IC 95%: 0,26; 0,55; p<0,0001) y una mayor tasa de patencia (RP 4,76; IC 95%: 2,14; 10,56; p<0,0001). Conclusión: Los pacientes con TVP aguda de extremidad inferior que reciben TDC se asocian con una menor incidencia de SPT y una mayor incidencia de tasa de patencia. En nuestro metanálisis, la TDC es un tratamiento efectivo para pacientes con TVP aguda de extremidad inferior.

Anesthesia for lower extremity vascular bypass with peripheral nerve block / Anestesia para bypass vascular em membro inferior com bloqueio de nervos periféricos

Abstract Vascular bypass is a surgical procedure widely used to treat peripheral vascular disease. The intraoperative anesthetic technique and the most appropriate postoperative analgesia for these high-risk patients remain controversial. We present the case of a patient undergoing femoropopliteal-distal bypass in our service, presenting with relevant comorbidities to the choice of anesthetic technique. This patient had several determining factors of difficult airway, especially thoracic kyphoscoliosis, which prevented him from being properly positioned for airway management, and chronic lung disease. This patient was also taken antiplatelet drugs, which is a contraindication for neuraxial block. So, we chose the anesthetic technique of peripheral nerve block, specifically the blockade of femoral and sciatic nerves.

Resumo A cirurgia para bypass vascular é um procedimento amplamente usado para o tratamento da insuficiência vascular periférica. A técnica anestésica para o intraoperatório e para analgesia pós-operatória mais apropriada para esses pacientes de alto risco ainda permanece controversa. Apresentaremos o caso de um paciente submetido a bypass femoropoplíteo distal no nosso serviço, que apresentava comorbidades relevantes para a escolha da técnica anestésica. Esse paciente apresentava fatores determinantes de via aérea difícil, principalmente cifoescoliose da coluna torácica, que o impedia de ser posicionado adequadamente para o manejo da via aérea, além de ser portador de patologia pulmonar crônica. Também fazia uso de antiplaquetários que contraindicavam o bloqueio de neuroeixo. Por isso, optou-se como técnica anestésica pelo bloqueio de nervos periféricos, especificamente o bloqueio dos nervos femoral e isquiático.

Topography of the middle genicular artery is associated with the superior and inferior genicular arteries / La topografía de la arteria genicular media está asociada con las arterias geniculares superiores e inferiores

Total knee arthroplasty has increased substantially, however anatomical studies of the genicular arteries (GAs) in this region are rare. The aim of this study was to identify the pattern and branching points of GAs and their relationship. In 42 lower limbs, the pattern and branching points of GAs were confirmed. The horizontal line which extends between the most prominent point of the lateral and medial margins of patella was defined as a reference line. The distance of branching point of the GAs from the reference line was measured, and the correlations between these points were analyzed. The superior lateral and medial genicular arteries (SLGA and SMGA) were located at + 38.17 ± 3.10 mm and + 32.68 ± 3.83 mm from the reference line, respectively. The middle genicular artery (MGA) was originated from + 7.57 ± 3.98 mm. The inferior lateral and medial genicular arteries (ILGA and IMGA) were located at - 18.46 ± 2.63 mm and - 24.09 ± 3.52 mm, respectively. The branching points of the SLGA changed significantly according to the arterial branching pattern with the MGA. In addition, the branching point of the MGA had positive relationships with that of the IMGA (r = 0.385, p <0.05) and that of the ILGA (r = 0.348, p <0.05), respectively. In this study, topography of the GAs and its anatomical association were demonstrated for the first time in Korean cadavers. Knowledge of the topography about frequent variation would be useful for safe surgery and clinical procedures.

La artroplastía total de rodilla ha aumentado sustancialmente, sin embargo los estudios anatómicos de las arterias geniculares (AGs) en esta región son escasos. El objetivo de este estudio fue identificar los patrones y puntos de ramificación de las AGs y sus relaciones. En 42 miembros inferiores, se identificaron el patrón y los puntos de ramificación de las AGs. La línea horizontal que se extiende entre el punto más prominente de los márgenes lateral y medial de la patela se definió como una línea de referencia. Se midió la distancia entre el punto de ramificación de las AGs y la línea de referencia, y se analizaron las correlaciones entre estos puntos. Las arterias geniculares superiores lateral y medial (AGSL y AGSM, respectivamente) se situaron a + 38,17 ± 3,10 mm y + 32,68 ± 3,83 mm de la línea de referencia, respectivamente, y la arteria genicular media (AGM) se originó a partir de + 7,57 ± 3,98 mm. Las arterias geniculares inferiores lateral y medial (AGIL e AGIM, respectivamente) se localizaron a - 18,46 ± 2,63 mm y - 24,09 ± 3,52 mm, respectivamente. Los puntos de ramificación de la AGSL cambiaron significativamente de acuerdo con el patrón de ramificación arterial con respecto a la AGSM. Además, el punto de ramificación de la AGSM tuvo relaciones positivas con el de la AGIM (r = 0.385, p <0.05) y el de la AGIL (r = 0.348, p <0.05). En este estudio, la topografía de las AGs y su asociación anatómica se demostraron por primera vez en cadáveres coreanos. El conocimiento de la topografía sobre la variación frecuente sería útil para su aplicación en el desarrollo de cirugías y procedimientos clínicos seguros.

Effect of dexmedetomidine on acute lung injury in experimental ischemia-reperfusion model / Efeito de dexmedetomidina sobre lesão pulmonar aguda em modelo experimental de isquemia-reperfusão

Abstract Purpose: Ischemia-reperfusion injury is one of the consequences of tourniquet application for extremity surgery. The aim of the study was to establish the effect of dexmedetomidine on the acute lung injury following lower extremity experimental ischemia-reperfusion model in rats. Methods: Twenty-eight Wistar-Albino breed Rats were recruited after Ethics Committee approval and allocated into 4 groups, each with 7 subjects. Group 1 (SHAM) received only anesthesia. Group 2 (IR) had experienced 3 h of ischemia and 3 h of reperfusion using left lower extremity tourniquet after anesthesia application. Groups 3 (D-50) and 4 (D-100) had undergone the same procedures as in the Group 2, except for receiving 50 and 100 mg·kg-1, respectively, dexmedetomidine intraperitoneally 1 h before the tourniquet release. Blood samples were obtained for the analysis of tumor necrosing factor-α and interleukin-6. Pulmonary tissue samples were obtained for histological analysis. Results: No significant difference regarding blood tumor necrosing factor-α and interleukin-6 values was found among the groups, whereas pulmonary tissue injury scores revealed significant difference. Histological scores obtained from the Group 2 were significantly higher from those in the Groups 1, 3 and 4 with p-values 0.001 for each comparison. Moreover, Group 1 scores were found to be significantly lower than those in the Groups 3 and 4 with p-values 0.001 and 0.011, respectively. No significant difference was observed between the Groups 3 and 4. Conclusion: Dexmedetomidine is effective in reduction of the experimental ischemia-reperfusion induced pulmonary tissue injury in rats, formed by extremity tourniquet application.

Resumo Objetivo: A lesão de isquemia-reperfusão é uma das consequências da aplicação do torniquete em cirurgias de extremidades. O objetivo do estudo foi determinar o efeito de dexmedetomidina em lesão pulmonar aguda após modelo experimental de isquemia-reperfusão em extremidade inferior de ratos. Métodos: Vinte e oito ratos albinos Wistar foram recrutados após aprovação do Comitê de Ética e alocados em quatro grupos, cada um com sete indivíduos. O Grupo 1 (Sham) recebeu apenas anestesia. O Grupo 2 (IR) foi submetido a 3 horas de isquemia e 3 horas de reperfusão com o uso de torniquete em extremidade inferior após a aplicação da anestesia. Os grupos 3 (D-50) e 4 (D-100) foram submetidos aos mesmos procedimentos do Grupo 2, exceto por receberem 50 e 100 mg.kg-1 de dexmedetomidina, respectivamente, por via intraperitoneal uma hora antes da liberação do torniquete. Amostras de sangue foram coletadas para análise de TNF-α e Interleucina-6 (IL-6). Amostras de tecido pulmonar foram coletadas para análise histológica. Resultados: Não houve diferença significativa quanto aos valores sanguíneos de TNF-α e IL-6 entre os grupos, enquanto os escores de lesão em tecidos pulmonares revelaram diferença significativa. Os escores histológicos obtidos no Grupo 2 foram significativamente maiores do que os dos grupos 1, 3 e 4, com valores-p de 0,001 para cada comparação. Além disso, os escores do Grupo 1 foram significativamente menores do que os dos grupos 3 e 4, com valores-p de 0,001 e 0,011, respectivamente. Não houve diferença significativa entre os grupos 3 e 4. Conclusão: Dexmedetomidina mostrou eficácia na redução de lesão em tecido pulmonar induzida por isquemia-reperfusão experimental em ratos, ocasionada por aplicação de torniquete em extremidade.

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy / Uso de dióxido de carbono como substituto ao contraste iodado em arteriografia durante embolectomia

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

A isquemia aguda de membro pode ser danosa para o membro e para a vida. A insuficiência renal é um desfecho possível associado à liberação dos produtos da reperfusão do membro isquêmico. Alguns autores relatam o benefício de realização de angiografia após embolectomia, apesar do contraste iodado também ser nefrotóxico. Relatamos um caso de embolectomia em uma paciente com insuficiência renal, em que o dióxido de carbono foi utilizado como substituto para o contraste iodado.

Biometric study of the bifurcations of the popliteal artery and the tibiofibular trunk / Estudio biométrico de las bifurcaciones de la arteria poplítea y del tronco tibiofibular

The popliteal artery is located deep inside the popliteal fossa, and is an important landmark in surgical procedures. Lesions of this vessel and its branches can be dangerous, blocking circulation to the lower limb and leading to gangrene or even vascular failure. The aim of this work was to describe the biometric characteristics of the bifurcations of the popliteal artery and the tibiofibular trunk in relation to the head of the fibula in 38 lower limbs through dissection. The bifurcation of the both arteries was present in all the cases. The mean confidence interval for the bifurcation of the popliteal artery was from 2.82 cm to 3.18 cm from the head of the fibula, and that of the bifurcation of the tibiofibular trunk was from 5.72 cm to 6.68 cm. The bifurcation of the popliteal artery into the anterior tibial artery and tibiofibular trunk showed a more constant positioning than the level of the birfurcation of the posterior tibial artery and fibular artery. These data can help in the development of new access routes to these arteries, or the optimization of surgical planning in the region in question.

La arteria poplítea se encuentra en la fosa del mismo nombre y es un punto de referencia importante en los procedimientos quirúrgicos. Las lesiones de este vaso y sus ramas pueden ser peligrosas, bloqueando la circulación a la extremidad inferior pudiendo llevar a gangrena o incluso a la insuficiencia vascular. El objetivo de este trabajo fue describir la anatomía de la arteria poplítea y el nivel de su primera bifurcación en tronco tibiofibular y arteria tibial anterior, y además el nivel de bifurcación del tronco en arterias tibial posterior y fibular (segunda bifurcación), en relación a la cabeza de la fíbula. Para ello se realizó disección en 38 miembros inferiores. El intervalo de confianza para la media de la primera bifurcación fue de 2,82 cm a 3,18 cm de la cabeza de la fíbula y la de la segunda bifurcación fue de 5,72 cm a 6,68 cm. La bifurcación de la arteria poplítea en la arteria tibial anterior y el tronco tibiofibular mostró un posicionamiento más constante que la altura de la bifurción de la arteria tibial posterior y la arteria fibular. Estos datos pueden ayudar en el desarrollo de nuevas vías de acceso a estas arterias, o la optimización de la planificación quirúrgica de la región.