Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care.

Difficult airway management in pediatrics during anesthesia represents a major challenge, requiring a careful approach, advanced technical expertise, and accurate protocols. The task force of the Brazilian Society of Anesthesiology (SBA) presents a report containing updated recommendations for the management of difficult airways in children and neonates. These recommendations have been developed based on the consensus of a panel of experts, with the objective of offering strategies to overcome challenges during airway management in pediatric patients. Grounded in evidence published in international guidelines and expert opinions, the report highlights crucial steps for the appropriate management of difficult airways in pediatrics, encompassing assessment, preparation, positioning, pre-oxygenation, minimizing trauma, and, paramountly, the maintenance of arterial oxygenation. The report also delves into additional strategies involving the use of advanced tools, such as video laryngoscopy, flexible intubating bronchoscopy, and supraglottic devices. Emphasis is placed on the simplicity of implementing the outlined recommendations, with a focus on the significance of continuous education, training through realistic simulations, and familiarity with the latest available technologies. These practices are deemed essential to ensure procedural safety and contribute to the enhancement of anesthesia outcomes in pediatrics.

Prevention of drug diversion and substance use disorders among anesthesiologists: a narrative review

Abstract Diversion of substances from the care of the intended patient is a significant problem in healthcare. Patients are harmed by the undertreatment of pain and suffering, transmission of disease, as well as the risk associated with impaired vigilance. Healthcare providers may be harmed by the physical and mental impact of their addictions. Healthcare systems are placed in jeopardy by the legal impact associated with illegal routes of drug release including sanction and financial liability and loss of public trust. Healthcare institutions have implemented many measures to reduce diversion from the perioperative area. These efforts include education, medical record surveillance, automated medication dispensing systems, urine drug testing, substance waste management systems, and drug diversion prevention teams. This narrative review evaluates strengths, weaknesses, and effectiveness of these systems and provides recommendations for leaders and care providers.

Comparison of intravenous and inhalation anesthesia on postoperative behavior changes in children undergoing ambulatory endoscopic procedures: A randomized clinical trial.

BACKGROUND: Early and delayed behavioral changes are well recognized after anesthesia. Intravenous anesthesia may prevent emergence delirium. However, it has not been evaluated as a preventive strategy for delayed postoperative behavior changes. AIMS: We aimed to determine whether intravenous anesthesia is effective at reducing postoperative behavior changes in children undergoing ambulatory endoscopic procedures when compared to inhalation anesthesia. METHODS: This randomized, double-blinded controlled trial was approved by the local IRB. Children aged 1-12 years who underwent ambulatory endoscopic procedures were recruited. Preoperative anxiety was evaluated through the modified Yale Preoperative Anxiety Scale. All children underwent face mask inhalation induction with sevoflurane. After a peripheral line was placed, each child was allocated to sevoflurane or propofol maintenance. Emergence delirium was evaluated through the Pediatric Anesthesia Emergence Delirium scale. The child was discharged home, and behavioral changes were assessed through the Posthospitalization Behavior Questionnaire for Ambulatory Surgery on Days 1, 7, and 14. RESULTS: Overall, 175 children were enrolled. On Day 1 after the procedure, 57 children presented at least one negative behavior. On Days 7 and 14, 49 and 44 children presented at least one negative behavior, respectively. The median number of negative behaviors was similar between the groups. Post hoc analyses showed a moderate correlation between emergence delirium and negative postoperative behavior on Day 7 (r = .34; p = <.001) and an increase of 3.31 (95% CI 1.90; 4.36 p < .001) points in the mean summed score of new negative behaviors for individuals with emergence delirium. CONCLUSION: The incidence of postoperative behavior changes in children undergoing ambulatory endoscopic procedures was similar when comparing intravenous with inhalation anesthesia. Children who experience emergence delirium might show a greater incidence of negative postoperative behavior changes.

Noninvasive intracranial pressure real-time waveform analysis monitor during prostatectomy robotic surgery and Trendelenburg position: case report.

Both robotic surgery and head-down tilt increase intracranial pressure by impairing venous blood outflow. Prostatectomy is commonly performed in elderly patients, who are more likely to develop postoperative cognitive disorders. Therefore, increased intracranial pressure could play an essential role in cognitive decline after surgery. We describe a case of a 69-year-old male who underwent a robotic prostatectomy. Noninvasive Brain4careTM intraoperative monitoring showed normal intracranial compliance during anesthesia induction, but it rapidly decreased after head-down tilt despite normal vital signs, low lung pressure, and adequate anesthesia depth. We conclude that there is a need for intraoperative intracranial compliance monitoring since there are major changes in cerebral compliance during surgery, which could potentially allow early identification and treatment of impaired cerebral complacency.

Anestesia para suprarrenalectomia em pacientes com feocromocitoma bilateral: relato de dois casos e considerações sobre o tema / Anesthesia for adrenalectomy in patients with bilateral pheochromocytoma: a two-case report and remarks on the topic

O feocromocitoma é um tumor raro, sendo sua incidência estimada em um a dois casos por 100.000 adultos. Ocorrem em aproximadamente 0,1% da população hipertensa, sendo importante causa de hipertensão arterial grave corrigível. O tratamento cirúrgico, com retirada total de todos os focos de tecido tumoral, constitui-se no único tratamento definitivo do feocromocitoma e pode ser realizado por via aberta ou videolaparoscópica. O preparo pré-operatório é realizado com o objetivo de tratar a hipertensão arterial, evitar a ocorrência de paroxismos e de corrigir uma eventual hipovolemia. Se isso não for feito, os pacientes correm o risco de desenvolver hipotensão importante e mesmo choque hipovolêmico após a retirada do tumor e consequente desaparecimento da vasoconstrição. Durante o procedimento cirúrgico, seja ele aberto ou laparoscópico, a pressão arterial média, a pressão venosa central, o ritmo e a frequência cardíaca devem ser continuamente monitorizados. As reações hipertensivas que acontecem, inevitavelmente, durante o manuseio cirúrgico do tumor devem ser tratadas com a infusão endovenosa de drogas de ação imediata, como o alfa-bloqueador adrenérgico fentolamina ou o vasodilatador de ação direta, nitroprussiato de sódio. Taquicardia e arritmias devem ser tratadas com a administração endovenosa de beta-bloqueadores. A administração de volume, principalmente após a retirada do tumor, deve ser efetuada quando os níveis de pressão arterial média e de pressão venosa central, associados a parâmetros clínicos e laboratoriais, indicarem a existência de hipovolemia. A maioria dos pacientes com hipotensão no pós-operatório responde bem à administração de volume, sendo raramente necessárias drogas vasoativas. Outra ocorrência possível, mas menos provável, nas primeiras 24 a 48 horas do pós-operatório é a hipoglicemia, sendo recomendado controle de glicemia capilar nas primeiras 48 horas do pós-operatório. O objetivo deste artigo é apresentar dois casos de ressecção de feocromocitoma realizados em nosso serviço e com diferentes evoluções e discutir os cuidados perioperatórios para esse tipo de cirurgia.(AU)

Pheochromocytoma is a rare tumor with estimated incidence of 2 cases per 100,000 adults. It affects approximately 0.1% of the hypertensive population, and is an important cause of a correctable form of severe arterial hypertension. Surgery to remove every focus of tumoral tissue is the only definitive treatment and can be performed either by incision or videolaparoscopy. Preoperative care is provided to treat arterial hypertension, avoid paroxysms, and correct eventual hypovolemia. Otherwise, patients may develop considerable hypotension and even hypovolemic shock after tumor removal and eventually loss of vasoconstriction. Irrespective of the type of surgery, mean arterial pressure, central venous pressure, and heart rhythm and rate must be continuously monitored during procedures. The hypertensive reactions that inevitably take place during surgical handling of the tumor must be treated with intravenous infusion of rapid acting drugs, such as the adrenergic alpha-blocker phentolamine or the direct action vasodilator sodium nitroprusside. Tachycardia and arrhythmia must be treated with intravenous infusion of beta-blockers. Administration of volume, especially after tumor removal, must be carried out when the levels of mean arterial pressure and central venous pressure, associated with clinical and laboratorial parameters, point to hypovolemia. Most patients with postoperative hypotension react well to the administration of volume, and vasoactive drugs are rarely needed. It is also possible, although usually unlikely, that patients have hypoglycemia in the first 24-48 hours after surgery; capillary blood glucose testing is thus recommended within the first 48 hours after surgery. This paper aims to report on two cases of pheochromocytoma resection carried out at our health care center, which progressed differently, and to discuss perioperative care issues for this type of surgery.(AU)

Análise da ocorrência de hipertensão intracraniana refratária e da resposta ao tratamento de crianças com traumatismo crânio-encefálico grave / Analysis of the incidence of refractory intracranial hypertension and the response of children with severe head trauma to the treatment

Introdução: o traumatismo crânio-encefálico (TCE) grave é frequente em pediatria, mas as recomendações para seu tratamento têm baixo nível de evidência. Objetivo: analisar a ocorrência de hipertensão intracraniana (HIC) refratária e a resposta ao tratamento em crianças com TCE grave. Métodos: coorte incluindo pacientes com pontuação abaixo de nove na Escala de Coma de Glasgow (ECG) entre setembro de 2005 e agosto de 2008. Aprovado pelo Comitê de Ética em Pesquisa da Fhemig. Resultados: analisados 156 pacientes, 116 masculinos (74,4%), idades entre três meses e 18 anos, média nove, mediana 11. Mediana da pontuação na ECG: 6. Atropelamento: 54 pacientes (34,6%); lesões em ocupantes de veículos: 34 (21,8%); queda: 21 (13,5%); e lesões em ciclistas: 18 (11,5%). Tomografia alterada: 133 pacientes (85,3%); hemorragia intracraniana: 105 (67,3%); swelling: 66 (42,3%); lesão axonal difusa: (28,8%). A monitorização da pressão intracraniana foi realizada em 73 pacientes (46,8%). Foi encontrada HIC com necessidade de tratamento em 56 (76,7%) e refratária em 30 (41%) pacientes. Destes pacientes, 10 receberam barbitúrico e sete morreram. A craniectomia descompressiva foi realizada em nove pacientes, sendo que dois faleceram. O risco relativo de morte com barbitú- rico: 3,9 (IC 95%: 1,1 a 14,1; p=0,02), com significância estatística. O risco relativo de morte com craniectomia descompressiva: 0,3 (IC95%: 0,1 a 1,0, p=0,02). Ocorreram 33 óbitos (21,1%), 59% de redução em relação a estudo anterior da Instituição. Conclusões: HIC refratária foi muito frequente em crianças com TCE grave. O uso de coma barbitúrico para seu tratamento aumentou o risco de morte em quatro vezes.(AU)

Background: Severe head trauma is common in children, but there is a lack of evidence for the intracranial hypertension treatment in the literature. Objectives: To analyze the occurrence of refractory intracranial hypertension and the response of children and adolescents with severe head trauma to the treatment. Method: Cohort study between September 2005 and August 2008 involving pediatric patients with Glasgow coma scale (GCS) from 3 to 8 points. This study was approved by the ethical committee of FHEMIG. Results: From the 156 patients, 116 were male (74,4%). The range of age varied from tree months to 18 years, mean age 9, and median 11. Median of GCS score: 6. Running over crash: 54 patients (34,6%), car occupants injuries: 34 (21,8%), falls: 21 (13,5%) e cyclist´s injuries: 18 (11,5%). Abnormalities in computed tomography: 133 patients (85,3%), intracranial hemorrhage: 105 (67,3%), swelling: 66 (42,3%), diffuse axonal injury: (28,8%). Seventy three patients received intracranial pressure monitoring (46,3%); 56 had had intracranial hypertension that needed treatment (76,7%), and 30 had had refractory intracranial hypertension (41%). From the patients with refractory hypertension, 10 received barbiturates as treatment, seven died. Nine underwent decompressive craniectomy, two died. Relative risk of death with barbiturates: 3,9 (CI 95%: 1,1 a 14,1; p=0,02). Relative risk of death with decompressive craniectomy: 0,3 (IC95%: 0,1 a 1,0, p=0,02). Total mortality rate was 21,1% (33 patients). This showed a decrease of 59% in mortality comparing to previous study done in the same hospital. Conclusion: refractory intracranial hypertension were very common in pediatric patients with severe head injury. The use of barbiturates for its treatment increased the risk of death four times.(AU)

Condutas anestésicas nas síndromes hemorrágicas obstétricas / Anesthetic management in obstetrical hemorrhagic syndromes

Este artigo de revisão tem como objetivo abordar de maneira geral as síndromes hemorrágicas obstétricas, especialmente as hemorragias pós-parto, com ênfase nas condutas anestésicas recomendadas pela literatura atualizada por meio de artigos, livros textos e medicina baseada em evidências.

This article reviews the hemorrhagic syndromes during pregnancy and pospartum, and current recommended anesthetic management of such conditions, through extensive analysis of updated review articles, text books and evidence-based medicine.