When the Conception of Symmetry Deceives Us: A Case Report on the Perioperative Diagnosis of Subclavian Artery Stenosis.

Subclavian artery stenosis is a relatively uncommon manifestation of peripheral artery disease with significant morbidity. We describe a case of left subclavian artery stenosis that became apparent in the intraoperative setting, in a patient who presented for emergency surgery after a fall and subsequent left femoral neck fracture. Initial non-invasive blood pressure readings on the left upper extremity were in the normal range but after placement of the arterial line on the right upper extremity, the discrepancy was evident pointing towards a structural abnormality as the causative factor. CT angiography was found to confirm the diagnosis of left subclavian artery stenosis of an atherosclerotic nature. A thorough physical examination can point to the presence of subclavian stenosis through pulse amplitude and blood pressure asymmetries. This study highlights the importance of obtaining blood pressure readings ideally on all four limbs to avoid misinterpretation of blood pressure values that could ultimately lead to the use of unnecessary and inadequate interventions and possible complications in the perioperative setting.

Incidence of postoperative residual neuromuscular blockade - A multicenter, observational study in Portugal (INSPIRE 2).

Background: Although the use of neuromuscular blocking agents (NMBAs) optimizes surgical conditions and facilitates tracheal intubation, it can lead to residual neuromuscular blockade (RNMB), with postoperative complications. This study aimed to assess RNMB incidence and management in Portugal. Methods: Prospective observational study of patients admitted for elective surgery requiring general anesthesia with nondepolarizing NMBAs between July 2018 and July 2019 at 10 Portuguese hospitals. The primary endpoint was the proportion of patients arriving at postanesthesia care unit (PACU) with a TOF ratio <0.9. Results: A total of 366 patients were included, with a median age of 59 years, and 89.1% classified as ASA II or III. Rocuronium was the most used NMBA (99.5%). A total of 96.2% of patients received a reversal agent, 96.6% of which sugammadex and 3.4% neostigmine. Twenty patients displayed a TOF ratio <0.9 at PACU arrival, representing an RNMB incidence of 5.5% (95% CI, 3.1%-7.8%). Only two patients displayed a TOF ratio <0.7. RNMB incidence was 16.7% with neostigmine and 5.3% with sugammadex (P = .114). In patients with intraoperative neuromuscular blockade (NMB) monitoring, RNMB incidence was 5% (95% CI, 2%-8%), which varied significantly according to the type of monitoring (P = .018). Incidence of adverse events was 3.3% (2 severe and 10 moderate). Conclusions: The reported overall incidence of 5.5% is numerically lower than results from similar observational studies. An appropriate pharmacological neuromuscular reversal strategy, guided by quantitative neuromuscular monitoring, has the potential to achieve even better results, converting RNMB from an unusual to a very rare or even inexistent event.

Adrenal Crisis During Cesarean Section in a Patient With Primary Adrenal Insufficiency.

Congenital adrenal hyperplasia (CAH) is a type of primary adrenal insufficiency (AI) that predisposes to adrenal crisis (AC) during stress. We describe a case of a primipara with CAH who was admitted in labor. To prevent AC, glucocorticoid replacement was given according to guidelines. Due to fetal decelerations, an emergency C-section was performed under general anesthesia following which refractory hypotension emerged. The diagnosis of AC was considered, and hydrocortisone was given with sustained hemodynamic improvement. AC is a life-threatening emergency whose diagnosis requires a high index of suspicion. Despite adequate steroid coverage, additional stressors may precipitate AC, so it is of paramount importance that anesthesiologists consider this emergency.

Cerebral Autoregulation in Unilateral Carotid Agenesis: How Low Can We Go?

Dysgenesis of the internal carotid artery (ICA) is a rare vascular disorder. It has a variety of different grades (agenesis, aplasia, and hypoplasia) and is more common on the right side. Although the ICA is an important vessel, most patients are asymptomatic due to collateral circulation. Recognition of this rare anomaly is important, particularly when considering patients for surgeries that demand permissive hypotension. We present and discuss the perioperative implications of a rare case of congenital absence of left carotid artery proposed for an urgent laryngeal biopsy and tracheostomy. The internal jugular vein was invaded with a tumor and so was removed, affecting venous drainage.

Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe: The EuroPOWER international observational study.

STUDY OBJECTIVE: Assess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes. DESIGN: Prospective cohort study. SETTING: European centers (185 hospitals) across 21 countries. PATIENTS: A total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020. INTERVENTIONS: Routine perioperative care. MEASUREMENTS: Twenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences. RESULTS: A total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79-1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5-9] vs. 8 [6-10] days; OR 0.82; 95%CI, 0.78-0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%-65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53-0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02-0.42; P = 0.002) and shorter hospital stay (6 [4-8] vs. 7 [5-10] days; OR 0.74; 95%CI, 0.69-0.79; P < 0.001). CONCLUSIONS: Treatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.

ATENA-A Novel Rapidly Manufactured Medical Invasive Ventilator Designed as a Response to the COVID-19 Pandemic: Testing Protocol, Safety, and Performance Validation.

Background: The urgent need for mechanical ventilators to support respiratory insufficiency due to SARS-CoV-2 led to a worldwide effort to develop low-cost, easily assembled, and locally manufactured ventilators. The ATENA ventilator project was developed in a community-based approach targeting the development, prototyping, testing, and decentralized manufacturing of a new mechanical ventilator. Objective: This article aims to demonstrate ATENA's adequate performance and safety for clinical use. Material: ATENA is a low-cost ventilator that can be rapidly manufactured, easily assembled, and locally produced anywhere in the world. It was developed following the guidelines and requirements provided by European and International Regulatory Authorities (MHRA, ISO 86201) and National Authorities (INFARMED). The device was thoroughly tested using laboratory lung simulators and animal models. Results: The device meets all the regulatory requirements for pandemic ventilators. Additionally, the pre-clinical experiences demonstrated security and adequate ventilation and oxygenation, in vivo. Conclusion: The ATENA ventilator had a good performance in required tests in laboratory scenarios and pre-clinical studies. In a pandemic context, ATENA is perfectly suited for safely treating patients in need of mechanical ventilation.

Postdural puncture headache in the obstetric population: a new approach?

BACKGROUND AND OBJECTIVES: The gold standard for the treatment of postdural puncture headache (PDPH) is the epidural blood patch (EBP). Regional techniques-sphenopalatine ganglion block (SPGB), greater occipital nerve block (GONB) and trigger point infiltration (TPI)-can also be used for the treatment of PDPH. Our objective was to evaluate the efficacy of these peripheral nerve blocks (PNBs) in the treatment of PDPH. METHODS: A retrospective study was conducted including all patients with PDPH in the obstetrics department of our institution between April 2016 and December 2017. Data were retrieved from clinical records regarding anesthetic technique, symptoms, treatment, Numeric Pain Score (NPS) before and after treatment, among others. RESULTS: We observed 50 cases of PDPH: 25 following spinal anesthesia, 19 following epidural block and 6 following combined spinal-epidural. Of these, seven were managed conservatively and one received EBP as first-line treatment. The remaining 42 patients received PNB as first-line treatment. Of these, 27 received only 1 course of PNB, while 15 received 2 courses. We observed a statistically significant improvement in the NPS after the first course of blocks (n=42), with a reduction of the median NPS by 6.0 (IQR 4.0-7.5; p<0.001). Improvement was also observed after the second course of blocks (n=15), with a reduction of the median NPS of 3.5 (IQR 1.5-5.0; p=0.02). Due to treatment failure, 9 of the 42 patients treated with PNB required EBP. None of these were cases following spinal anesthesia. CONCLUSION: SPGB, GONB and TPI can be safe and effective options for treatment of PDPH, but do not completely eliminate the need for EBP. Prospective studies designed to identify factors associated with unsuccessful treatment are required.

Misinterpretation and Limitations of pEEG Monitoring During Multimodal General Anesthesia: A Case Report.

The adequate titration of hypnotic agents can be achieved using processed electroencephalogram (pEEG) monitors. pEEG monitors with a spectrogram, such as bilateral bispectral index (BIS), are useful because they can show different signatures that suggest the effect of a given drug on brain activity. Multimodal general anesthesia is based on a combination of hypnotic and antinociceptive agents. We report a case of awareness in a patient monitored with bilateral BIS during multimodal general anesthesia. This case illustrates the limitations of the index and the value of the spectrogram in the assessment of hypnosis.

Population Pharmacokinetic-Pharmacodynamic Modeling for Propofol Anesthesia Guided by the Bispectral Index (BIS).

This study aimed to develop a population pharmacokinetic-pharmacodynamic (PKPD) model for propofol using data prospectively collected from a heterogeneous group of adult, elderly, and obese patients using the bispectral index (BIS) as a pharmacodynamic guide. Adult, obese (body mass index ≥35 kg/m2 ), and elderly patients (aged >65 years) were included. Propofol infusion was started at 2000 mg/h until loss of consciousness and then guided by target BIS values (40-60). Measurements of propofol plasma concentration were performed using gas chromatography. A PKPD model was developed using NONMEM. The data set contained 423 propofol concentrations and 483 897 BIS values from 60 patients (20-92 years, 42-136 kg). A 3-compartment model was used to describe the plasma concentrations of propofol. An allometric model using lean body weight calculated by the Janmahasatian formula was found to describe the data better than total body weight for all clearance parameters, V1 and V2. An age effect was found on Q2, Q3, V1, and V3. With respect to the PD model, the use of a 2-compartment model significantly improved the model fit. Age and total body weight were included as covariates in the final pharmacodynamic model. We propose a PKPD model for propofol anesthesia with acceptable performance accuracy in a heterogeneous group of adult, elderly, and obese patients. A new method to predict propofol induction dose is presented. This method and the possibility to directly change target BIS values in opposition to the assumed target effect-site concentration constitutes certain advantages to the clinical practice.

Interscalene plexus block and general anesthesia in Brugada syndrome.

Brugada syndrome (BrS) is a channelopathy predisposing to malignant ventricular arrhythmias and sudden cardiac death. Perioperative pharmacological and physiological changes may precipitate these events and cardiac dysfunction. We report the efficacy and safety interscalene brachial plexus block combined with general anesthesia in a patient with BrS. Awake and double-guided interscalene block was performed. After performing the block, general anesthesia was induced with fentanyl, propofol and rocuronium and maintained with oxygen-air/sevoflurane mixture. Sugammadex was administered for neuromuscular reversal. During perioperative period, the patient remained hemodynamically stable with anormal sinus rhythm and no ST segment changes. Hospital discharged occurred 36h after surgery without complications. General recommendations include avoidance of increased vagal tone, correction of electrolytes disturbances, maintenance of normothermia, normocapnia, adequate analgesia, and an adequately deep plane of anesthesia. Interscalene block combined with general anesthesia provided good analgesia, hemodynamic and cardiac electric stability.

Bioelectrical impedance analysis of body composition for the anesthetic induction dose of propofol in older patients.

BACKGROUND: Older people are currently the fastest growing segment of the worldwide population. The present study aimed to estimate propofol dose in older patients based on size descriptors measured by bioelectrical impedance analysis (BIA). METHODS: A cross sectional study in adult and older patients with body mass index equal to or lower than 35 kg/m2 was carried out. BIA and Clinical Frail Scale scoring were performed during pre-operative evaluation. Propofol infusion was started at 2000 mg/h until loss of consciousness (LOC) which was defined by "loss of eye-lash reflex" and "loss of response to name calling". Total dose of propofol at LOC was recorded. Propofol plasma concentration was measured using gas chromatography/ion trap-mass spectrometry. RESULTS: Forty patients were enrolled in the study. Total propofol dose required to LOC was lower in Age ≥ 65 group and a higher plasma propofol concentration was measured in this group. 60% of old patients were classified as "apparently vulnerable" or "frail" and narrow phase angle values were associated with increasing vulnerability scores. In the Age ≥ 65 group, the correlation analysis showed that the relationship between propofol dose and total body weight (TBW) scaled by the corresponding phase angle value is stronger than the correlation between propofol dose and TBW or fat free mass (FFM). CONCLUSIONS: This study demonstrates that weight-based reduction of propofol is suitable in older patients; however FFM was not seen to be more effective than TBW to predict the propofol induction dose in these patients. Guiding propofol induction dose according to baseline frailty score should also be considered to estimate individualized dosage profiles. Determination of phase angle value appears to be an easy and reliable tool to assess frailty in older patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02713698 . Registered on 23 February 2016.

Idiopathic histiocytoid Sweet syndrome: a case report with clinical and histopathological considerations.

BACKGROUND: Histiocytoid Sweet syndrome is characterized by a predominant neutrophilic dermal infiltrate. Usual clinical differential diagnosis includes erythema multiforme, drug eruption, and erythema nodosum. Histiocytoid Sweet syndrome is considered an uncommon histopathological variant of the disease. METHODS: We evaluated clinical, histopathological, and immunohistochemical findings of a case categorized as idiopathic histiocytoid Sweet syndrome in which clinical-epidemiological data raised the possibilities of Sweet syndrome, leprosy, and drug reaction. RESULTS: Positive reaction to myeloperoxidase (MPO) in histiocytoid cells of the dermal infiltrate, response to oral corticosteroids, clinical and laboratory investigation, and absence of cutaneous lesions or clinical complaints within 1 year of follow-up are consistent with the diagnosis of idiopathic histiocytoid Sweet syndrome. CD68 (PG-M1) and CD15 positive cells were also present among dermal cells. CONCLUSIONS: Epidemiological data are relevant while considering a clinical differential diagnosis of Sweet syndrome that can be further expanded, from a histopathological point of view, when dealing with the histiocytoid variant since neutrophils, macrophages, and immature myelomonocytic cells with histiocytoid morphology are present. The significance of the MPO positive mononuclear dermal cells are not completely established.

Effect of Boussignac continuous positive airway pressure ventilation on Pao2 and Pao2/Fio2 ratio immediately after extubation in morbidly obese patients undergoing bariatric surgery: a randomized controlled trial.

STUDY OBJECTIVE: Pathophysiological changes after laparoscopic Roux-en-Y gastric bypass may increase the risk of pulmonary complications in morbidly obese patients. The purpose of the study was to assess the impact of immediate postextubation use of Boussignac continuous positive airway pressure (CPAP) on arterial oxygenation in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass. The hypothesis is that the use of CPAP may improve oxygenation in the postoperative period when compared to Venturi mask. DESIGN: Randomized controlled study. SETTING: A tertiary referral hospital. PATIENTS: Recruited morbidly obese adult patients undergoing laparoscopic Roux-en-Y gastric bypass. INTERVENTIONS: Boussignac CPAP or Venturi mask was randomly applied immediately after extubation in the operating room and was maintained during the first 2 hours in the recovery room. MEASUREMENTS: Pao2 and Pao2/fraction of inspired oxygen (Fio2) ratio values were measured preoperatively and at 1 (T1), 2 (T2), and 24 hours (T24) after extubation, through arterial blood samples. Secondary outcomes (spirometric parameters) were measured at the same periods. For comparison between groups, Student t test, Mann-Whitney U nonparametric test, and χ(2) test were used. Statistical significance is at P < .05. MAIN RESULTS: Twenty-four patients were included, 12 in each group. There were no differences in preoperative evaluation. There were significant differences between groups in Pao2 and Pao2/Fio2 mean values at T1, T2, and T24, being superior in the Boussignac group. During the 24 hours postextubation, 9% of patients in the Boussignac group and 50% in the Venturi group had a Pao2 less than 60 mm Hg in at least 1 of the evaluations. After extubation, a Pao2/Fio2 ratio value less than 300 was observed in all patients in the Venturi group and in 55% in Boussignac group in at least 1 of the evaluations. There were no differences in spirometric parameters between groups at T1, T2, and T24. CONCLUSIONS: Application of Boussignac CPAP for 2 hours after extubation improved oxygenation but did not improve forced expiratory volume at 1 second and forced vital capacity.

Increased lung inflammation with oxygen supplementation in tracheotomized spontaneously breathing rabbits: an experimental prospective randomized study.

BACKGROUND: Mechanical ventilation is a well-known trigger for lung inflammation. Research focuses on tidal volume reduction to prevent ventilator-induced lung injury. Mechanical ventilation is usually applied with higher than physiological oxygen fractions. The purpose of this study was to investigate the after effect of oxygen supplementation during a spontaneous ventilation set up, in order to avoid the inflammatory response linked to mechanical ventilation. METHODS: A prospective randomised study using New Zealand rabbits in a university research laboratory was carried out. Rabbits (n = 20) were randomly assigned to 4 groups (n = 5 each group). Groups 1 and 2 were submitted to 0.5 L/min oxygen supplementation, for 20 or 75 minutes, respectively; groups 3 and 4 were left at room air for 20 or 75 minutes. Ketamine/xylazine was administered for induction and maintenance of anaesthesia. Lungs were obtained for histological examination in light microscopy. RESULTS: All animals survived the complete experiment. Procedure duration did not influence the degree of inflammatory response. The hyperoxic environment was confirmed by blood gas analyses in animals that were subjected to oxygen supplementation, and was accompanied with lower mean respiratory rates. The non-oxygen supplemented group had lower mean oxygen arterial partial pressures and higher mean respiratory rates during the procedure. All animals showed some inflammatory lung response. However, rabbits submitted to oxygen supplementation showed significant more lung inflammation (Odds ratio = 16), characterized by more infiltrates and with higher cell counts; the acute inflammatory response cells was mainly constituted by eosinophils and neutrophils, with a relative proportion of 80 to 20% respectively. This cellular observation in lung tissue did not correlate with a similar increase in peripheral blood analysis. CONCLUSIONS: Oxygen supplementation in spontaneous breathing is associated with an increased inflammatory response when compared to breathing normal room air. This inflammatory response was mainly constituted with polymorphonuclear cells (eosinophils and neutrophils). As confirmed in all animals by peripheral blood analyses, the eosinophilic inflammatory response was a local organ event.

[High blood pressure prevalence in Oporto sedentary and regular exercise practicing people]. / Prevalência do diagnóstico de hipertensão arterial em pessoas sedentárias e em praticantes de exercício físico, na cidade do Porto.

INTRODUCTION: The association between the lack of exercise and prevalence of high blood pressure (HBP) is a well known fact. The non-pharmacological treatment for HBP includes regular aerobic exercise practicing. METHODS: A total of 900 individuals, aged above 40, resident in Oporto, representing the 15 parishes of the city, were approached to answer a questionnaire about exercise habits and diagnosis of HBP. The exercise practitioner was defined as the one who practices aerobic exercise for a minimal period of 30 minutes at least 3 times a week. For data analysis non-parametric tests (Pearson's Chi-Square) were used through the Statistical Package for the Social Sciences (SPSS) software. RESULTS: The HBP prevalence in the sample was 39.67% (Confidence Interval (IC) 95%, 36,46% to 42,87%). The HBP prevalence in the exercise practitioners was inferior to the one of the non-practitioners (13,78% vs 25,89%, p < 0,001). This result is valid to the male 33,5% vs 51,6%, p < 0,001) and female population (27,1% vs 51,9%, p < 0,001), as well as to the population without the most frequent HBP-related comorbidities (21,8% vs 44,6%, p < 0,001). CONCLUSIONS: The HBP prevalence in the population resident in Oporto city is higher in the non-practitioners of regular exercise. The HBP prevalence, in both sexes, is higher in the non-practitioners of exercise. Finally, we can also conclude that the studied comorbidities don't bias the obtained results because the group of individuals who don't have them the HBP prevalence is still higher in the group of sedentary.

Effect of cigar smoking on endothelium-dependent brachial artery dilation in healthy young adults.

BACKGROUND: Cigar smoking has become a quickly growing trend among teenagers, women, and young adults. The objective was to explore whether cigar smoking affects flow-mediated vasodilation in healthy, non-smoking young adults. METHODS: This was a prospective randomized trial with open design. It was performed in a cardiology teaching program in a private community hospital that serves as a major referral center within the greater Miami area. Apparently healthy, non-smoking young adult cardiology trainees and staff between the ages of 20 and 45 years were randomly assigned to a cigar smoking group (n = 15) or a control group (n = 14). The main outcome measures were the difference in percent diameter increase in the brachial artery after reactive hyperemia and sublingual nitroglycerin between members of the cigar smoking and control groups at baseline, measured after cigar smoking, and at 5 hours. RESULTS: Twenty-nine participants were randomized. Percent diameter increase in the brachial artery was measured with the use of high-resolution ultrasonography. Baseline percent diameter increase after reactive hyperemia and sublingual nitroglycerin was similar in both groups (6.2% vs 6.7%, P = .4 and 22% vs 23%, P = .5, respectively). We observed a 2.5% increase in brachial artery diameter with hyperemia after cigar smoking compared with a 9.4% increase in the control group, P = .045. Values after nitroglycerin were similar between groups, P = .2. Between-group analysis showed no significant difference in percent dilation after reactive hyperemia at 5 hours, P = .4, but a significant difference was seen after sublingual nitroglycerin, P = .02. CONCLUSIONS: These data are compatible with the possibility that cigar smoking may have an acute effect on endothelium-dependent, flow-mediated brachial artery dilation and do not support the possibility of an immediate effect on endothelium-independent vasodilation. Taken together, these results suggest that cigars are not an innocuous alternative to cigarette smoking.