Prevalence of obstructive sleep apnea syndrome and predictors of difficult orotracheal intubation.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is an underdiagnosed condition that causes recurrent episodes of partial or total collapse of the upper airways during sleep. It is associated with perioperative pulmonary complications. The STOP-BANG is a screening tool for assessing patients at risk of OSAS. The aim of this study was to assess the prevalence of patients with OSAS during pre-anesthetic evaluation at a hospital and its correlation with predictors of ventilation and difficult airway. METHODS: This is an observational, cross-sectional study carried out from January 2022 to September 2023. The questionnaire comprised demographic data (age, weight, BMI, type of surgery, and anesthesia), the STOP-BANG, predictors of difficult orotracheal intubation (Mallampati, mouth opening, thyromental distance, cervical mobility, and upper lip bite test), and predictors of difficult ventilation through a facial mask (male sex, absence of teeth, presence of beard, obesity, and >55 years). RESULTS: The study had the participation of 221 patients, of whom 121 presented with a STOP-BANG ≥3, with a prevalence of 54.2%. All patients undergoing bariatric surgeries presented STOP-BANG ≥3. No significant statistical relationships were found between predictors of difficult orotracheal intubation and STOP-BANG ≥3. However, significant statistical relationships were found in relation to predictors of difficult ventilation through the facial mask.

Injúria miocárdica aguda em paciente com miocardiopatia secundária à Ataxia de Friedreich / Acute myocardial injury in a patient with cardiomyopathy secondary to Friedreich's Ataxia

CASO: Paciente portador de Ataxia de Friedreich, internou-se no serviço com quadros gripais e assintomático do ponto de vista cardiovascular nos anos de 2021 e 2022, teste de covid negativos, onde apresentou alteração da troponina ultrassensível para níveis de 1400pg/ml com BNPs normais e foi submetido à ressonância magnética do coração (RMC) em 2021 que evidenciou FEVE discretamente reduzida de 46% à custa de hipocinesia difusa, hipertrofia concêntrica, ausência de edema miocárdico/ mapas t1 e t2 nativos preservados, realce tardio (RT) mesoepicárdico na parede lateral basal e transmural na parede lateral média. Troponina do paciente após 3 meses da alta hospitalar encontrava-se em 850pg/ml, 2 anos após 570pg/ml e 3 anos após 321pg/ml. RMC de 12/2023 evidenciou FEVE de 48% à custa da hipocinesia difusa, aumento concêntrico do VE, com maior espessura de 14mm das paredes inferior e lateral e mesmo padrão do RT. DISCUSSÃO: A ataxia de Friedreich (AF) é um distúrbio neuromuscular raro (3­4 casos por 100.000 indivíduos) causado por uma expansão repetida do trinucleotídeo guaninaadenina-adenina (GAA) no gene da frataxina (FXN) que resulta em expressão reduzida da FXN, uma proteína mitocondrial. A AF é caracterizada por coordenação prejudicada como resultado de déficits cerebelares e sensoriais. Alterações induzidas pela AF na fisiologia mitocondrial podem afetar o coração. A remodelação concêntrica do ventrículo esquerdo (VE) tem sido bem descrita nos pacientes, paralelamente à diminuição do volume diastólico e da fração de ejeção do ventrículo esquerdo (FEVE) progressivamente. Eventos cardíacos foram considerados a principal causa de mortalidade em ∼60% dos pacientes com AF ­ evolução para morte com <40 anos. Conforme descrito no estudo CARFA, 50% dos pacientes tinham padrão de realce miocárdico transmural/ subepicárdico da parede lateral e aumento de troponina relacionados ao aumento da espessura miocárdica. O paciente do caso com provável miocardite na RMC 2021, mantendo-se com altos níveis de troponina basal anos após os eventos gripais, com diversas alterações estruturais do VE prévias e realces com características possíveis para doenças sobrepostas. CONCLUSÃO: O caso clínico tem como objetivo dar ênfase nas alterações cardíacas inerentes à rara AF, inclusive seu padrão de realce miocárdico e aumento da troponina basal para a consideração dos diagnósticos diferenciais, como neste caso de quadro de injúria miocárdica aguda com RT presente na RMC.

Acompanhamento laboratorial e funcional em paciente com miocardite crônica pós- COVID-19: um relato de caso / Laboratory and functional monitoring in a patient with chronic post-COVID-19 myocarditis: a case report

INTRODUÇÃO: A miocardite é uma doença inflamatória do miocárdio que pode ser causada por diversos agentes, incluindo a COVID-19, na fase crônica, o paciente pode apresentar o desenvolvimento da miocardiopatia dilatada (MD). Apresentamos um caso de um paciente com MD pós COVID-19. CASO: Paciente do sexo masculino, 45 anos, obeso, diagnosticado com tireoidite de Hashimoto, faz uso de levotiroxina 200mg e aspirina 100mg, com histórico de doença coronariana familiar precoce. Foi encaminhado para a emergência após consulta para investigação de dispneia aos esforços pós-infecção da SARS-CoV-2 há 2 meses, na qual evidenciou através da tomografia computadorizada com achados sugestivos de COVID-19 e cardiomegalia com derrame pericárdico. O paciente foi internado para investigação do quadro, os exames laboratoriais demonstraram hormônios tireoidianos dentro da faixa de normalidade, peptídeo natriurético cerebral (BNP) de 11.800 pg/mL e troponina de 573 ng/mL. Foi realizado um ecocardiograma que revelou uma fração de ejeção (FE) de 19%, dilatação moderada e déficit contrátil em ventrículo esquerdo (VE), dilatação biatrial importante, ventrículo direito dilatado, função sistólica reduzida e pericárdio espessado com derrame discreto. Durante o internamento, não apresentou intercorrências, e fez uso de: nitroglicerina, betabloqueador e diurético. Na angioressonância magnética do coração (angio-RM), foram evidenciados achados que fortaleceram a hipótese clínica de miocardite prévia, descartando etiologia isquêmica, com uma FE de 12%. Após 8 dias no hospital, o paciente recebeu alta. Três meses após, o paciente retornou para consulta sem dispnéia, em uso de losartana, dapagliflozina, furosemida, espironolactona, bisoprolol, ivabradina, rosuvastatina e levotiroxina, trazendo uma angio-RM com FE de 47,6% e BNP em queda, de 1018 pg/mL. CONCLUSÃO: Os exames laboratoriais como a elevação de troponina e BNP foram observadas em casos de miocardite por Covid-19 e no caso, esses, estiveram correlacionados aos achados funcionais cardíacos, como FE. O significado da correlação é incerto, mas pode oferecer dados para diagnóstico e acompanhamento da MD pós COVID-19 no futuro.

Diagnóstico de variantes de Miocardiopatia Primária (MP) DSP E MYH7 em paciente jovem pós-parada cardíaca: relato de caso / Diagnosis of variants of Primary Cardiomyopathy (PM) DSP and MYH7 in a young post-cardiac arrest patient: case report

INTRODUÇÃO: A identificação precoce de um portador de MP através de teste genético revela etiologias com maior potencial arritmogênico ou de pior prognóstico, sendo possível instituir medidas para retardar a progressão da doença e evitar um desfecho súbito maligno. Apresentamos um caso de uma paciente portadora de variantes genéticas pós parada cardíaca. CASO: Paciente do sexo feminino, 27 anos, apresentou episódio de tontura e síncope enquanto jogava vôlei, apresentando movimentos tônico-clônicos, cianose perioral, perda esfincteriana e mordedura de língua. Ao chegar na emergência, foi realizado exame neurológico e tomografia computadorizada de crânio, ambos sem alterações. Durante o seu internamento foi realizado um ecocardiograma que revelou uma insuficiência cardíaca com ventrículo esquerdo (VE) e átrio esquerdo aumentados com uma fração de ejeção de 33% e uma disfunção sistólica do tipo 1. Realizada uma angioressonância magnética do coração que teve como resultado uma disfunção sistólica com fração de ejeção de 22%, com alteração da contratilidade segmentar e discreta dilatação do VE, além de uma fibrose miocárdica extensa não isquêmica com predomínio na parede anterior, lateral e posterior (ring-like). Também foi realizado um holter que evidenciou uma atividade ectópica ventricular de 1313 extra-sístoles isoladas e 19 pares. A paciente foi submetida a implante de cardiodesfibrilador implantável subcutâneo, sem intercorrências. Além disso, foi prosseguida avaliação genética para cardiomiopatia hereditária, através de um painel genético, que evidenciou a presença de duas variantes de significado incerto em heterozigose nos genes DSP e MYH7, relacionadas a cardiomiopatias e arritmias, além disso havia antecedente de morte súbita durante atividade física aos 42 anos. CONCLUSÃO: A identificação de variantes genéticas em pacientes jovens deve ser pensada para aqueles com história familiar de morte súbita cardíaca em jovens ou eventos cardiovasculares nessa mesma faixa etária, a fim de permitir melhor prognóstico. O objetivo seria a prevenção de eventos súbitos, como também oferecer condutas clínicas e cirúrgicas mais precisas.

The Analgesic Effects of the Thoracic Paravertebral Block on Post-percutaneous Nephrolithotripsy: A Retrospective Study.

INTRODUCTION: Percutaneous nephrolithotripsy (PCNL) is a minimally invasive procedure for treating large and complex kidney stones, often resulting in significant post-operative pain and increased opioid use. This study aims to compare pain scores between patients undergoing PCNL who did and did not receive a preoperative single-shot thoracic paravertebral block (PVB) at the post-anesthesia care unit (PACU) as the primary outcome. Secondary outcomes were patient-controlled analgesia (PCA) usage on post-operative day 1 (POD 1), total opioid consumption on PACU and POD 1, and post-operative nausea and vomiting (PONV). METHODS: A retrospective cohort study was conducted on the medical records of 341 patients who underwent PCNL from July 2014 to April 2016 in a single major academic center. PVB was administered at thoracic levels T7-9 using a volume of 20 cc of bupivacaine, ranging from 0.25% to 0.5%, to achieve the desired analgesic effect. RESULTS: After excluding 34 patients, the study included 123 in the no block (NB) group and 149 in the regional anesthesia (RA) group. There were no differences in demographics, including age, sex, weight and height, BMI, and indication for PCNL. The results revealed that the RA group experienced a statistically significant reduction in PCA usage in both crude and adjusted models (adjusted logistic regression analysis: OR = 0.19, 95% CI = 0.05-0.60; p = 0.008). However, there were no significant changes in total opioid consumption, pain scores, or incidents of PONV. CONCLUSION: The retrospective analysis did not reveal any discernible advantage in pain management associated with the use of PVB for post-PCNL analgesia, except for reducing the percentage of PCA narcotics used. Future investigations with larger sample sizes and meticulous control for surgical indications and complexity are imperative to accurately assess the efficacy of this block in the context of post-PCNL surgery.

Psychosocial Factors Associated With Vulvodynia.

OBJECTIVES: We set out to identify the psychosocial factors associated with vulvodynia and the effects on sexuality, mental health, and quality of life. MATERIALS AND METHODS: PubMed, LILACS, Embase, CINAHL, Web of Science, Scopus, and PsycINFO were searched in August 2023. Two authors selected and extracted the data independently. The risk of bias was assessed using the Newcastle-Ottawa Scale for Observational Studies. To rank the strength of evidence, the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) approach was utilized. RESULTS: A total of 3,182 articles were identified. Twenty-two observational studies (8 cohorts and 14 case-controls) met the eligibility criteria and were included, comprising 2,624 patients. Vulvodynia has been associated with psychological factors (anxiety and depression) and social factors (childhood exposure to physical and sexual abuse, posttraumatic stress, and domestic abuse). Concerning sexual function, the most frequent outcomes were dyspareunia and sexual dysfunction. Only one study assessed quality of life, which showed that women with chronic vulvar pain had greater difficulty performing physical activities and experienced negative moods and feelings. The assessment of the risk of bias showed that the average quality of studies was good to excellent. However, the studies failed to select the nonexposed cohort or control group to describe the results, and often, the study population was rather small, which made it impossible to carry out a meta-analysis. CONCLUSIONS: The certainty of evidence for the associations between anxiety and depression, vulvodynia, and sexual functioning suggests that combating these factors could improve overall quality of life in vulvodynia patients.

Intraoperative and immediate postoperative transfusion: Clinical-hematological profile of transfunded patients in a university hospital.

INTRODUCTION: The transfusion practice by surgery blood reserve, varied among services, must be performed through the rational and restrictive use of blood components because it is a scarce and expensive resource for health care services. OBJECTIVE: Analyze the use of blood products for surgery blood reserve by means of the study of the clinical-hematological profile of patients submitted to intraoperative and immediate postoperative transfusions. METHODS: This was an observational, cross-sectional, and retrospective study, conducted by collecting biological, operational, and laboratory variables, involving 680 patients at a university hospital who had elective surgery with surgery blood reserve request sent during the period from October 2021 to October 2022. RESULTS: The overall transfusion rate was 25.44%, and the mean preoperative hemoglobin level of transfused patients was 9.74 ± 2.50 g/dL, with the mean number of transfusions packed red blood cell units was 1.58 ± 0.77. Patients with higher preoperative hemoglobin levels were less likely to have transfusion (p < 0.001) and patients who had surgical oncologic were more likely to require transfusion (p = 0.048). The transfusion rate of packed red blood cells and platelets concentrates, compared to what was requested, was 15.86% and 5.82%. CONCLUSION: There is a tendency of transfusions to follow restrictive models, with higher transfusion probability in surgical oncologic. Furthermore, there should be more a conscise use of the surgery blood reserves request.

Vestibular Symptoms Following a Retrobulbar Block: A Case Report.

A 62-year-old male patient presented for cataract surgery under retrobulbar block anesthesia. After the regional block, the patient exhibited sudden onset and progressive symptoms of nausea, vomiting, central-type vertigo, and hearing loss. These symptoms subsided within 2 hours, and the patient was discharged after 2 days without any residual effects. This report demonstrates a combination of auditory and vertiginous symptoms after a retrobulbar block. It emphasizes continuous care and vigilance when using regional anesthesia due to the potential risks and varied complications.

Thoracic Epidural Anesthesia After a Transversus Abdominis Plane Block With Liposomal Bupivacaine in a Patient With Chronic Opioid Use: A Case Report.

Liposomal bupivacaine is a long-acting local anesthetic drug that provides extended analgesia. A 45-year-old man with metastatic colon cancer and an intrathecal morphine pump for chronic pain underwent a transverse colectomy for a malignant transverse colon obstruction in this case report. The patient reported severe pain despite preoperative fascial plane blocks with liposomal bupivacaine and postoperative pain management strategies. As a result, an exploratory laparotomy was performed to rule out any underlying causes, but no new injuries were discovered. On postoperative day 1, a thoracic epidural catheter was inserted to provide better pain relief for the patient. The patient's pain was well-controlled by postoperative day 4, allowing the epidural catheter to be removed. On postoperative day 5, the patient was discharged home without complications. This case highlights the difficulties in managing post-laparotomy pain as well as the potential benefits of combining multiple analgesic modalities. It also emphasizes the pharmacokinetic properties of liposomal bupivacaine, emphasizing the need for caution due to its prolonged systemic presence and potential for systemic anesthetic toxicity.

Superior Trunk Block Is an Effective Phrenic-Sparing Alternative to Interscalene Block for Shoulder Arthroscopy: A Systematic Review and Meta-Analysis.

The interscalene block (ISB) is the standard regional anesthesia for shoulder arthroscopy. However, the superior trunk block (STB) is an alternative with a potentially safer profile. This meta-analysis aimed to compare the incidence and degree of hemidiaphragmatic paralysis and block efficacy of these techniques. We searched MEDLINE, EMBASE, Scopus, and Cochrane databases to identify randomized controlled trials (RCTs). The main outcome was total hemidiaphragmatic paralysis. We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence. Four RCTs and 359 patients were included. The STB group showed lower total hemidiaphragmatic paralysis (RR 0.07; 95% CI 0.04 to 0.14; p<0.0001). The incidence of subjective dyspnea (p = 0.002) and Horner's syndrome (p<0.001) was significantly lower with STB relative to ISB. There was no significant difference between groups in block duration (p = 0.67). There was a high certainty of evidence in the main outcome as per the GRADE framework. Our findings suggest that STB has a better safety profile than ISB, resulting in lower rates of hemidiaphragmatic paralysis and dyspnea while providing a similar block. Therefore, STB could be preferred to ISB, especially in patients susceptible to phrenic nerve paralysis complications.

Latex-Free Anesthesia for Craniosynostosis Surgery Associated With Xia-Gibbs Syndrome: A Case Report.

This case report describes the anesthetic management of a one-year-old patient with Xia-Gibbs syndrome, which is a rare genetic condition caused by a mutation in the AHDC1 gene. The procedure involved calvarial vault remodeling and fronto-orbital advancement to correct a left coronal craniosynostosis. In addition, the patient had a history of seizures and latex-fruit syndrome, which necessitated careful preoperative planning and management. Despite the difficulties provided by the patient's cranial abnormalities and the paucity of literature on anesthetic experiences with the condition, the treatment was completed successfully and without complications. Insights are offered about the anesthetic approach for this syndromic pediatric patient undergoing neurosurgery with a high risk of bleeding. It is important to understand and prepare for the perioperative implications of this disease in order to achieve a safe outcome.

Opioid-Free Anesthesia for Awake Neurosurgery in a Patient With Asthma and Von Willebrand Disease: A Case Report.

Anesthesia for awake neurosurgery requires meticulous planning. We report the case of a 44-year-old female with glioblastoma undergoing an awake craniotomy. Due to her asthma and von Willebrand disease, an opioid-free approach was chosen. Conscious sedation was attained using propofol and dexmedetomidine. The operation was successful after nine hours with patient comfort maintained. The patient was discharged from the intensive care unit in two days without sequelae. However, the use of desmopressin caused hyponatremia and cerebral edema. The scalp block was effective for pain management. This case highlights the importance of individualized anesthetic strategies in awake neurosurgeries.

Exploring the Potential of Lidocaine in a Bilateral Erector Spinae Plane Block for Multimodal Analgesia in Partial Hepatectomy: A Case Report.

The bilateral erector spinae plane block (ESP) has been effectively used for abdominal surgery, and the placement of catheters is known to extend the benefits of the block while allowing for the adjustment of local anesthetic doses as necessary. Since fascial plane blocks require high volumes of local anesthetic and a prolonged duration of effect, typically, long-acting local anesthetics are preferred. However, lidocaine is not commonly chosen for these types of blocks due to the large volumes required and the associated risk of local anesthetic systemic toxicity. Nonetheless, we present a case report of a patient who underwent a partial hepatectomy under general anesthesia, with perioperative placement of a bilateral ESP block. Bilateral catheters were inserted, and 1% lidocaine was selected as the local anesthetic due to resource limitations. The surgery proceeded without complications, and the patient reported effective analgesia and a high level of satisfaction. Our report suggests that the utilization of lidocaine in a continuous ESP block can be a successful alternative for partial hepatectomies.

A Comparison Between Saline and Balanced Solutions in Kidney Transplants: A Randomized Clinical Trial.

Objective This study aimed to investigate the impact of different types of intravenous fluids - normal saline (NS), lactated Ringer's solution (LR), and PlasmaLyte (PL) - on the acid-base balance and electrolyte concentration following kidney transplant, a common procedure for patients with end-stage renal disease (ESRD). Methodology A randomized controlled trial design was employed, wherein the primary parameters analyzed were postoperative pH and serum potassium levels. Postoperative concentrations of serum bicarbonate, sodium, chloride, and creatinine, as well as graft functionality, were assessed as secondary outcomes. These measurements were performed at the start and end of surgery, as well as 24 and 72 hours postoperatively. Results A total of 53 patients were included in the study and randomized into three cohorts: NS, LR, and PL, each of which showed comparability in terms of demographic and transplantation specifics. Notably, patients in the NS group exhibited a more significant decrease in pH (NS group: 7.285 ±0.098, LR group: 7.324 ±0.075, PL group: 7.7338 ±0.059) and bicarbonate levels (17.0 ±4.2, 20.9 ±2.8, 20.0 ±4.5) post 24 hours after the operation and displayed a similar pattern immediately after the surgery. However, there were no discernible differences in potassium (p=0.460), sodium (p=0.681), and chloride (p=0.321) levels across the groups. Furthermore, the study did not observe any significant differences in postoperative graft functionality. Conclusion The use of NS as the intraoperative fluid of choice led to lower pH and bicarbonate levels following kidney transplant, as compared to LR and PL. However, these results did not correlate with improvements in graft functionality.

Malformação arteriovenosa pulmonar como causa de acidente vascular cerebral embólico / Pulmonary arteriovenous malformation as a cause of embolic stroke

APRESENTAÇÃO CLÍNICA: Paciente do sexo feminino, 31 anos, em uso de puran T4 50 mcg por dia devido a hipotireoidismo. Em novembro de 2020, deu entrada no pronto-socorro com diagnóstico de acidente vascular cerebral isquêmico cerebelar, sendo realizada extensa investigação, sem causa aparente. O Eco transesofágico realizado em novembro de 2020 mostrou septo interatrial com descolamento da lâmina da fossa oval de 3mm sem shunt espontâneo. Quando foi realizado teste com macrobolhas (6 tentativas) com grande quantidade de bolhas chegando ao átrio esquerdo, não sendo observadas pelo forame oval.

Infarto agudo do miocárdio no atleta saudável em uso abusivo de bebida energética / Acute myocardial infarction in a healthy athlete in abusive use of energy drink

INTRODUÇÃO: Bebidas energéticas (BEs) estão ganhando popularidade a cada ano, com uma ampla base de consumidores, incluindo jovens, atletas, competidores amadores. As evidências indicam que um número significativo de indivíduos, que consomem a bebida, experimentam morbidade e/ou mortalidade associado ao uso; Como apresentado no ACC 2019, o subestudo do registro "Young MI" mostrou que em pacientes com idade menor de 40 anos, o Infarto agudo do miocárdio (IAM) estava mais associado ao uso dessas substâncias. O objetivo deste relato é demonstrar a associação do uso de energético e IAM em paciente jovem, sem outro fator de risco. RELATO DE CASO: Paciente do sexo masculino, 37 anos, proveniente de Caruaru-PE, atleta, sem fator de risco cardiovascular. Negava uso de drogas, tabagismo, apenas uso abusivo de energéticos com base de Taurina. Apresentou quadro inicial de dor epigástrica em queimação associada ou não ao esforço. Inicialmente atribuiu sintomas à gastrite, fez endoscopia digestiva alta que apresentou esofagite erosiva leve, fez uso de inibidor de bomba de prótons, sem melhora dos sintomas. Fazia "check up" de rotina, onde realizou teste ergométrico em Abril 2017, sem alterações. Em março de 2018, paciente apresentou dor precordial importante (10/10) ao jogar futebol e procurou pronto atendimento. Realizado eletrocardiograma com presença de onda T apiculada e elevação ponto J de 1. 5 mm em V2 e V3. Submetido à cineangiocoronariografia que evidenciou artéria descendente anterior (DA) com lesão importante em terço proximal, sem demais lesões. DISCUSSÃO: O uso de BEs está associado ao aumento de agregação e disfunção plaquetária, hiperglicemia, bem como um aumento no total colesterol, triglicérides e lipoproteína de baixa densidade colesterol. A maioria dos efeitos biológicos das BEs é aparentemente mediada por um efeito inotrópico positivo na função cardíaca, que implica aumento da frequência cardíaca, do débito cardíaco e contratilidade, volume sistólico e pressão arterial. Worthley et al. Administrou uma lata de BE sem açúcar a 15 adultos jovens saudáveis e observou que a agregação plaquetária foi substancialmente aumentada até para 134%, enquanto a função endotelial foi inibida. Compostos das BEs como a taurina, a carnitina, e a glicuronolactona promovem disfunção endotelial e aterosclerose. CONCLUSÃO: Esse relato tem como objetivo dar ênfase ao desencorajamento do uso de bebidas energéticas, sendo possível fator causal de IAM em indivíduos saudáveis.