Perioperative management of patients on glucagon-like peptide-1 receptor agonists.

PURPOSE OF REVIEW: To summarize the mechanism of action, clinical outcomes, and perioperative implications of glucagon-like peptide-1 receptor agonists (GLP-1-RAs). Specifically, this review focuses on the available literature surrounding complications (primarily, bronchoaspiration) and current recommendations, as well as knowledge gaps and future research directions on the perioperative management of GLP-1-RAs. RECENT FINDINGS: GLP-1-RAs are known to delay gastric emptying. Accordingly, recent case reports and retrospective observational studies, while anecdotal, suggest that the perioperative use of GLP-1-RAs may increase the risk of bronchoaspiration despite fasting intervals that comply with (and often exceed) current guidelines. As a result, guidelines and safety bulletins have been published by several Anesthesiology Societies. SUMMARY: While rapidly emerging evidence suggests that perioperative GLP-1-RAs use is associated with delayed gastric emptying and increased risk of bronchoaspiration (particularly in patients undergoing general anesthesia and/or deep sedation), high-quality studies are needed to provide definitive answers with respect to the safety and duration of preoperative drug cessation, and optimal fasting intervals according to the specific GLP-1-RA agent, the dose/duration of administration, and patient-specific factors. Meanwhile, clinicians must be aware of the potential risks associated with the perioperative use of GLP-1-RAs and follow the recommendations put forth by their respective Anesthesiology Societies.

Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes

Abstract Introduction and objectives Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. Methods Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). Results Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p< 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p< 0.05). Conclusion MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

Comparison of three intraoperative analgesic strategies in laparoscopic bariatric surgery: a retrospective study of immediate postoperative outcomes.

INTRODUCTION AND OBJECTIVES: Multimodal Analgesia (MMA) has shown promising results in postoperative outcomes across a broad spectrum of surgeries, including bariatric surgery. We compared the analgesic effect immediately after Laparoscopic Bariatric Surgery (LBS) of the combined effect of MMA and methadone against two techniques that were based mainly on the use of high-potency medium-acting opioids. METHODS: Two hundred seventy-one patients were retrospectively reviewed. The primary outcome was postoperative pain score > 3/10 measured by the Verbal Numeric Scale (VNS) during the Postanesthetic Care Unit (PACU) stay. The three protocols of intraoperative analgesia were: (P1) sufentanil at anesthetic induction followed by remifentanil infusion; (P2) sufentanil at induction followed by dexmedetomidine infusion; and (P3) remifentanil at induction followed by MMA including dexmedetomidine, magnesium, lidocaine, and methadone. Only P1 and P2 patients received morphine toward the end of surgery. Poisson regression was used to adjust confounding factors and calculate Prevalence Ratio (PR). RESULTS: Postoperative VNS > 3 was recorded in 135 (49.81%) patients, of which 93 (68.89%) were subjected to P1, 25 (18.56%) to P2, and 17 (12.59%) to P3. In the final adjusted model, both anesthetic techniques (P3) (PR = 0.10; 95% CI [0.03-0.28]), and (P2) (PR = 0.42%; 95% CI [0.20-0.90]) were associated with lower occurrence of VNS > 3, whereas age range 20-29 was associated to higher occurrence of VNS > 3 (PR = 3.21; 95% CI [1.22-8.44]) in PACU. Postoperative Nausea and Vomiting (PONV) was distributed as follows: (P1) 20.3%, (P2) 31.25% and (P3) 6.77%; (P3 < P1, P2; p < 0.05). Intraoperative hypotension occurred more often in P3 (39%) compared to P2 (20.31%) and P1 (17.46%) (p < 0.05). CONCLUSION: MMA + methadone was associated with higher incidence of intraoperative hypotension and lower incidence of moderate/severe pain in PACU after LBS.

Impact of educational strategies on pain control quality indicators at a tertiary hospital / Impacto de estratégias educativas nos indicadores de qualidade do controle de dor em um hospital de alta complexidade

ABSTRACT BACKGROUND AND OBJECTIVES: Pain management by the multidisciplinary team remains a challenge in the health field. The aim of this study was to analyze the impact of educational strategies for the implementation of pain as the fifth vital sign and its management in a highly complex hospital. METHODS: An interventional non-controlled study analyzed three different sequential educational processes: Pain training week (PW), educational visits by the pain nurse to guide professionals in relation to pain management and e-learning. The impact of the educational strategy was assessed through pain as the 5th vital sign and adequate pain management. RESULTS: For pain as the 5th vital sign, the audit previous to PW showed a median of compliance of 46.4% at the inpatient unit, 53.1% at the maternity ward and 16.7% at the emergency room. In the evaluations after PW, the median of compliance at the inpatient unit was 78.4%, at the maternity ward 79.62% and at the emergency room 32.9% (p<0.05). There was an improvement in pain management in all hospital sectors after subsequent training (p<0.05). CONCLUSION: The implementation of a continuing education program has improved pain care assistance and increased compliance to the institutional pain protocol.

RESUMO JUSTIFICATIVA E OBJETIVOS: O manejo da dor pela equipe multidisciplinar continua como um desafio na saúde. O objetivo deste estudo foi analisar o impacto de estratégias educacionais para efetivação da dor como 5º sinal vital e seu gerenciamento em um hospital de alta complexidade. MÉTODOS: Estudo não controlado de intervenção por meio de análise de três diferentes estratégias educativas sequenciais: Semana de treinamentos sobre Dor (SD), visitas educacionais pelo enfermeiro da dor para orientar os profissionais em relação à dor e treinamento eletrônico virtual de revisão. A análise do impacto das estratégias educativas foi realizada por meio de indicadores em relação à dor como 5º sinal vital e tratamento adequado da dor. RESULTADOS: Na avaliação da dor como 5° sinal vital, a auditoria prévia à SD mostrou mediana de conformidade de 46,4% na unidade de internação, de 53,1% na maternidade e de 16,7% no Pronto Socorro. Nas avaliações após a SD, a mediana de conformidade na unidade de internação foi de 78,4%, na maternidade de 79,62% e no pronto atendimento de 32,9% (p<0,05). Houve melhora no tratamento da dor em todos os setores após avaliações subsequentes aos treinamentos (p<0,05). CONCLUSÃO: A implantação de um programa de educação continuada se mostrou efetivo em promover melhora na assistência no cuidado ao paciente com dor e dos resultados dos indicadores assistenciais em relação ao protocolo de dor institucional.

Bedside tests to predict laryngoscopic difficulty in pediatric patients.

BACKGROUND AND OBJECTIVES: Pediatric airway management is a priority during anesthesia, critical care and emergency medicine. The purpose of this study is to validate bedside tests that predict airway management difficulty in anesthetized children. METHODS: Children under 12 years of age were recruited in a cross-sectional study to assess the value of some anthropometric measures as predictors of laryngoscopic difficulty. The patients were divided into three groups by age. Weight, height, neck circumference, BMI (body mass index), inter incisors distance thyromental distance, sternomental distance, frontal plane to chin distance (FPCD) and the Mallampati index were determined and were correlated with the CML (Cormack & Lehane classification). RESULTS: The incidence of difficult laryngoscopy (CML 3 or 4) was 3.58%. Factors that were significantly associated with laryngoscopic difficulty included short inter incisors distance, high FPCD, thyromental distance, sternomental distance and the Mallampati index. The FPCD/weight index exhibited a higher area under the ROC curve than any other variable considered. CONCLUSIONS: This study confirms that the FPCD and the FPCD/weight ratio are the most consistent predictors of laryngoscopic difficulty in pediatric patients. For patients over 6 months of age, the IID also correlated with laryngoscopic difficulty. For children who were capable of obeying simple orders, the Mallampati test correlated better with laryngoscopic difficulty than did the Mallampati test with phonation. Our results strongly suggest that skilled professionals should perform airway management in children, especially in patients with a high FPCD or a high FPCD/weight ratio.

Parecoxib reduces renal injury in an ischemia/reperfusion model in rats.

PURPOSE: To evaluate the effect of parecoxib (an NSAID) on renal function by measuring plasma NGAL (serum neutrophil gelatinase-associated lipocalin) levels in an induced-ischemia rat model. METHODS: Forty male Wistar rats were randomly assigned to one of four groups: Ischemia (I), Ischemia/parecoxib (IP), No-ischemia (NI), and No-ischemia/parecoxib (NIP). Body weight, mean arterial pressure, heart rate, body temperature, NGAL levels, and renal histology were compared across groups. RESULTS: The Ischemia (I) group, which did not receive parecoxib, showed the highest NGAL levels (p=0.001), while the IP group, which received the medication, had NGAL levels similar to those of the non-ischemic (NI and NIP) groups. CONCLUSION: Parecoxib resulted in renal protection in this experimental model.

Parecoxib reduces renal injury in an ischemia/reperfusion model in rats

PURPOSE: To evaluate the effect of parecoxib (an NSAID) on renal function by measuring plasma NGAL (serum neutrophil gelatinase-associated lipocalin) levels in an induced-ischemia rat model. METHODS: Forty male Wistar rats were randomly assigned to one of four groups: Ischemia (I), Ischemia/parecoxib (IP), No-ischemia (NI), and No-ischemia/parecoxib (NIP). Body weight, mean arterial pressure, heart rate, body temperature, NGAL levels, and renal histology were compared across groups. RESULTS: The Ischemia (I) group, which did not receive parecoxib, showed the highest NGAL levels (p=0.001), while the IP group, which received the medication, had NGAL levels similar to those of the non-ischemic (NI and NIP) groups. CONCLUSION: Parecoxib resulted in renal protection in this experimental model. .

Fatores associados à dor pós-operatória na recuperação pós-anestésica em pacientes submetidos à gastroplastia laparoscópica / Factors associated to postoperative pain in the post-anesthetic care unit in patients submitted to laparoscopic gastroplasty

JUSTIFICATIVA E OBJETIVOS: A dor pós-operatória em pacientes obesos é um evento prejudicial para sua recuperação, retardando a alta e aumentando a chance de complicações. O objetivo deste estudo foi determinar a frequência de dor na sala de recuperação pós-anestésica e averiguar os fatores associados à ocorrência de dor moderada ou intensa em obesos submetidos a gastroplastia, relacionando-os a possíveis complicações. MÉTODOS: Estudo observacional prospectivo incluindo 84 pacientes submetidos a anestesia geral com sevoflurano para gastroplastia laparoscópica. Na sala de recuperação pós-anestésica, os pacientes foram avaliados quanto à intensidade da dor pela escala numérica e verbal, sedação (escala de Ramsay), ocorrência de náuseas, vômitos e complicações respiratórias. O modelo de regressão logística foi utilizado para determinar as variáveis independentes associadas à dor. RESULTADOS: Na sala de recuperação pós-anestésica, a ausência de dor na admissão ocorreu em 61,63% dos pacientes. Na análise multivariada, o uso do opioide fentanil em comparação ao sufentanil foi o único fator independentemente associado à dor (RR 3,07 - IC95% 1,17-6,4). Não houve diferença entre o tipo de opioide utilizado e a ocorrência de náuseas e vômitos (p>0,05). Os escores da escala de Ramsay não diferiram entre os tipos de opioides utilizados no intraoperatório (p>0,05). CONCLUSÃO: O único fator independentemente associado à dor na sala de recuperação pós-anestésica foi o tipo de opioide utilizado na indução anestésica. A dor pós-operatória ainda é um evento frequente que acomete a maioria dos pacientes e protocolos de analgesia precisam ser implementados para minimizar os efeitos que a dor subtratada pode causar.

BACKGROUND AND OBJECTIVES: Postoperative pain in obese patients is a noxious event for their recovery delaying hospital discharge and increasing the chance of complications. This study aimed at determining pain frequency in the post-anesthetic care unit and at investigating factors associated to moderate to severe pain in obese patients submitted to gastroplasty, relating them to potential complications. METHODS: This is an observational and prospective study including 84 patients submitted to general anesthesia with sevoflurane for laparoscopic gastroplasty. Patients were evaluated in the post-anesthetic care unit for pain intensity by the verbal and numerical scale (Ramsay scale), presence of nausea, vomiting and respiratory complications. Logistic regression model was used to determine pain-related independent variables. RESULTS: There has been no pain at admission to the post-anesthetic care unit in 61.63% of patients. In the multivariate analysis, fentanyl as compared to sufentanil was the only independent factor associated to pain (OR 3.07 - IC95% 1.17 - 6.4). There has been no difference between the type of opioid used and the presence of nausea and vomiting (p>0.05). Ramsay scale scores were not different between opioids used in the intraoperative period (p>0.05). CONCLUSION: The only independent factor associated to pain in the post-anesthetic care unit was the type of opioid used for anesthetic induction. Postoperative pain is still a frequent event affecting most patients, and analgesic protocols have to be implemented to minimize the effects that undertreated pain may induce.

Prevention of renal ischemia/reperfusion injury in rats using acetylcysteine after anesthesia with isoflurane.

PURPOSE: To evaluate the effect of N-acetylcysteine, as a renoprotective agent, when administered early after anesthesia induction, against ischemia/reperfusion injury in rats anesthetized with isoflurane. METHODS: Eighteen male Wistar rats weighing > 300 g were anesthetized with isoflurane. The internal jugular vein and the left carotid artery were dissected and cannulated. The animals were randomly divided into GAcetyl, receiving intravenous N-acetylcysteine, 300 mg/kg, and GIsot, isotonic saline. After 30 minutes, right nephrectomy was performed and the left renal artery was clamped during 45 minutes. The animals were sacrificed after 48 hours and blood samples were taken after anesthetic induction and upon sacrificing of the animals to evaluate blood creatinine. The kidneys were sent for histological analysis. RESULTS: The variation in serum creatinine was 2.33 mg/dL ± 2.21 in GAcetyl and 4.38 mg/dL ± 2.13 in GIsot (p=0.074). Two animals presented intense tubular necrosis in GAcetyl, compared to 5 in GIsot. Only GAcetyl presented animals free of tubular necrosis (two) and tubular degeneration (one). CONCLUSION: After renal ischemia/reperfusion, the rats which were given N-acetylcysteine presented less variation in serum creatinine and milder kidney injuries than the control group.

Prevention of renal ischemia/reperfusion injury in rats using acetylcysteine after anesthesia with isoflurane / Prevenção de lesão de isquemia/reperfusão em ratos com acetilcisteína após anestesia com isoflurano

PURPOSE: To evaluate the effect of N-acetylcysteine, as a renoprotective agent, when administered early after anesthesia induction, against ischemia/reperfusion injury in rats anesthetized with isoflurane. METHODS: Eighteen male Wistar rats weighing > 300g were anesthetized with isoflurane. The internal jugular vein and the left carotid artery were dissected and cannulated. The animals were randomly divided into GAcetyl, receiving intravenous N-acetylcysteine, 300mg/kg, and GIsot, isotonic saline. After 30 minutes, right nephrectomy was performed and the left renal artery was clamped during 45 minutes. The animals were sacrificed after 48 hours and blood samples were taken after anesthetic induction and upon sacrificing of the animals to evaluate blood creatinine. The kidneys were sent for histological analysis. RESULTS: The variation in serum creatinine was 2.33mg/dL ± 2.21 in GAcetyl and 4.38mg/dL ± 2.13 in GIsot (p=0.074). Two animals presented intense tubular necrosis in GAcetyl, compared to 5 in GIsot. Only GAcetyl presented animals free of tubular necrosis (two) and tubular degeneration (one). CONCLUSION: After renal ischemia/reperfusion, the rats which were given N-acetylcysteine presented less variation in serum creatinine and milder kidney injuries than the control group.

OBJETIVO: Avaliar o efeito da N-acetilcisteína na proteção renal contra lesão de isquemia/reperfusão, quando administrada logo após a indução anestésica, em ratos anestesiados com isoflurano. MÉTODOS: Dezoito ratos Wistar machos pesando mais que 300g foram anestesiados com isoflurano. A jugular interna direita e a carótida esquerda foram dissecadas e canuladas. Os animais foram distribuídos aleatoriamente em GAcetil, recebendo N-acetilcisteína por via intravenosa, 300mg/kg, e GIsot, solução salina. Foi realizada nefrectomia direita e clampeamento da artéria renal esquerda por 45 min. Os animais foram sacrificados após 48h, sendo colhidas amostras sanguíneas após a indução anestésica e ao sacrifício dos mesmos para avaliar a creatinina sérica. Realizou-se histologia renal. RESULTADOS: A variação da creatinina foi 2,33mg/dL ± 2,21 no GAcetil e 4,38mg/dL ± 2,13 no GIsot (p=0,074). Dois animais apresentaram necrose tubular intensa no GAcetil, comparados a cinco no GIsot. Apenas GAcetil apresentou animais livres de necrose tubular (dois) e degeneração tubular (um). CONCLUSÃO: Após isquemia/reperfusão renais, os ratos aos quais se administrou N-acetilcisteína apresentaram menor variação na creatinina sérica e lesões renais mais leves que o grupo controle.

Renal histology and immunohistochemistry after acute hemorrhage in rats under sevoflurane and ketoprofen effect / Histologia e imuno-histoquímica renais após hemorragia aguda em ratos sob efeito do sevoflurano e cetoprofeno

PURPOSE: To investigate the influence of intravenous nonselective cyclooxygenase inhibitor, ketoprofen (keto), on kidney histological changes and kidney cytokines, tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1), levels after hemorrhage of 30 percent of volemia (three times 10 percent, intervals of 10 min) in rats. METHODS: Under sevoflurane (sevo) anesthesia, sevo and sevo+keto groups (10 rats each) were instrumented for Ringer solution (5mL/kg/h) administration and mean arterial pressure (MAP) evaluation, plus keto (1.5mg/kg) administration in sevo+keto group in the beginning of anesthesia. Rectal temperature was continuously measured. The baseline data of temperature and MAP were collected at the first hemorrhage (T1), the third hemorrhage (T2) and 30min after T2 (T3). Bilateral nephrectomy was achieved for histology and immunohistochemistry. RESULTS: In both groups, temperature and MAP diminished from initial values. Hypothermia was greater in sevo group (p=0.0002). Tubular necrosis was more frequent in sevo group (p=0.02). The studied cytokines were equally present in the kidneys of both groups. CONCLUSION: Ketoprofen was more protective to the rat kidney in condition of anesthesia with sevoflurane and hypovolemia, but it seems that TNF-α and IL-1 were not involved in that protection.

OBJETIVO: Investigar a influência do inibidor não-seletivo da ciclooxigenase, cetoprofeno (ceto) intravenoso, em alterações histológicas e dos níveis das citocinas renais - fator α de necrose tumoral (TNF- α) e interleucina 1 (IL-1) - após hemorragia de 30 por cento da volemia (10 por cento, três vezes, em intervalos de 10 min). MÉTODOS: Sob anestesia com sevoflurano (sevo), os grupos sevo e sevo+ceto (10 ratos cada) foram preparados cirurgicamente para leitura de pressão arterial média (PAM) e administração de solução de Ringer (5 mL/kg/h) e de cetoprofeno (1,5 mg/kg), no início da anestesia, no grupo sevo+ceto. Mediu-se temperatura retal continuamente. Os valores de temperatura e PAM foram observados antes da primeira hemorragia (T1), após a terceira hemorragia (T2) e 30 min após T2 (T3). Realizada nefrectomia bilateral nos dois grupos para análise histológica e imuno-histoquímica. RESULTADOS: Nos dois grupos, temperatura e PAM diminuíram com relação aos valores basais. Hipotermia foi mais acentuada no grupo sevo (p=0,0002). Necrose tubular foi mais frequente no grupo sevo (p=0,02). As citocinas estiveram igualmente presentes nos rins dos dois grupos. CONCLUSÃO: Cetoprofeno foi mais protetor no rim de rato durante anestesia com sevoflurano e hipovolemia, porém parece que TNF- α e IL-1 não estão envolvidas nessa proteção.

Renal histology and immunohistochemistry after acute hemorrhage in rats under sevoflurane and ketoprofen effect.

PURPOSE: To investigate the influence of intravenous nonselective cyclooxygenase inhibitor, ketoprofen (keto), on kidney histological changes and kidney cytokines, tumor necrosis factor-α (TNF-α) and interleukin-1 (IL-1), levels after hemorrhage of 30% of volemia (three times 10%, intervals of 10 min) in rats. METHODS: Under sevoflurane (sevo) anesthesia, sevo and sevo+keto groups (10 rats each) were instrumented for Ringer solution (5 mL/kg/h) administration and mean arterial pressure (MAP) evaluation, plus keto (1.5mg/kg) administration in sevo+keto group in the beginning of anesthesia. Rectal temperature was continuously measured. The baseline data of temperature and MAP were collected at the first hemorrhage (T1), the third hemorrhage (T2) and 30 min after T2 (T3). Bilateral nephrectomy was achieved for histology and immunohistochemistry. RESULTS: In both groups, temperature and MAP diminished from initial values. Hypothermia was greater in sevo group (p=0.0002). Tubular necrosis was more frequent in sevo group (p=0.02). The studied cytokines were equally present in the kidneys of both groups. CONCLUSION: Ketoprofen was more protective to the rat kidney in condition of anesthesia with sevoflurane and hypovolemia, but it seems that TNF-α and IL-1 were not involved in that protection.

Patient perceptions about anesthesia and anesthesiologists before and after surgical procedures.

CONTEXT AND OBJECTIVE: Anesthesiologist-patient relationships are established preoperatively and intraoperatively. These are opportunities for providing correct information about anesthesia/anesthesiologists, thereby improving outcomes. The aim here was to evaluate patients' perceptions about anesthesiologists before anesthesia and to identify whether the anesthetic care would change such perceptions. DESIGN AND SETTING: Prospective cross-sectional study using data obtained in 2007-2008, at a tertiary university hospital. METHODS: 518 patients aged 16 years or over were interviewed before and after anesthesia exposure. A questionnaire was used to determine patient characteristics and perceptions of anesthesia/anesthesiologists. RESULTS: The patients were 16-89 years of age and 59.8% had attended elementary school. 79.1% said that anesthesiologists were specialized physicians. Anesthesiologists' roles were associated with loss of consciousness (35.5% pre-anesthesia; 43.5% post-anesthesia), pain relief (29.7% pre-anesthesia, 31.7% post-anesthesia), vital sign monitoring (17.6% pre-anesthesia, 35% post-anesthesia; P < 0.05); and drug administration (10.8% pre-anesthesia, 43.9% post-anesthesia; P < 0.05). The level of confidence in the physician was rated high (82.2% and 89.8% pre- and post-anesthesia, respectively; P < 0.05) or intermediate (5.8% and 6.6% pre- and post-anesthesia, respectively; P < 0.05). The care provided by anesthesiologists was classified as: elucidating (52.8%), encouraging (52.6%), neutral (10.2%) and careless (0.8%). CONCLUSION: Patients' perceptions of anesthesiologists' roles were fairly good, but improvements in this relationship still need to be pursued, to achieve better outcomes. Anesthetic care was important in providing information, confidence and reassurance among patients, regarding their perceptions. Anesthesiologists should not miss opportunities to provide excellent professional care for patients, thereby improving anesthesia outcomes and their image.

Dexmedetomidina e S(+)-cetamina em lesão de isquemia e reperfusão no rim de rato / Dexmedetomidine and S(+)-ketamine in ischemia and reperfusion injury in the rat kidney

PURPOSE: To investigate blood creatinine and renal histology in rats anesthetized with S(+)-ketamine (keta) or dexmedetomidine (dex) and submitted to kidney ischemia/reperfusion injury (IRI). METHODS: Under intraperitoneal (ip) S(+)-ketamine, 20 male Wistar rats were divided into two groups (n=10): maintenance with iv S(+)-ketamine or dex (keta and dex groups), and submitted to right (R) nephrectomy and left (L) renal artery clamping for 45 min. Blood creatinine was measured before ischemia (T1) and 48h after reperfusion (T2), when L nephrectomy was performed. Histological analysis was performed in all kidneys. RESULTS: Blood creatinine was significantly higher at T2 in both groups, but dex group results were lower than those of keta group. Histological changes: between groups, R kidneys did not differ; there were significant high scores for vascular dilation: keta L kidneys; for vascular congestion, tubular dilation, and necrosis: L kidneys from both groups; for tubular degeneration: keta R kidneys. CONCLUSION: S(+)-ketamine plus IRI were aggressive to rat kidneys, according to histological changes, and dexmedetomidine may have not totally protected the kidneys from these injuries, despite the better results of blood creatinine.

OBJETIVO: Investigar a creatinina sanguínea e histologia renal em ratos anestesiados com S(+)-cetamina (ceta) ou dexmedetomidina (dex) e submetidos à lesão de isquemia/reperfusão renal (IR). MÉTODOS: Sob S(+)-cetamina intraperitoneal (ip), 20 ratos Wistar machos foram distribuídos em dois grupos (n=10): manutenção com S(+)-cetamina ou dexmedetomidina, iv, (grupos ceta e dex), e submetidos à nefrectomia direita (D) e clampeamento da artéria renal esquerda (E) por 45 min. A creatinina sanguínea foi dosada antes da isquemia (T1) e 48h após a reperfusão (T2), quando foi realizada nefrectomia E. Houve análise histológica de todos os rins. RESULTADOS: A creatinina foi significativamente maior em T2 em ambos os grupos, porém menor com a dexmedetomidina. Alterações histológicas: entre grupos, os rins Ds não diferiram; houve escores altos significativos para dilatação vascular: rins Es do grupo ceta; para congestão vascular, dilatação tubular, necrose: rins Es de ambos os grupos; para degeneração tubular: rins Ds do grupo ceta. CONCLUSÃO: S(+)-cetamina e IR foram agressivas histologicamente para rins de ratos e a dexmedetomidina pode não ter protegido totalmente os rins dessas lesões, apesar dos melhores resultados de creatinina.

Dexmedetomidine and S(+)-ketamine in ischemia and reperfusion injury in the rat kidney.

PURPOSE: To investigate blood creatinine and renal histology in rats anesthetized with S(+)-ketamine (keta) or dexmedetomidine (dex) and submitted to kidney ischemia/reperfusion injury (IRI). METHODS: Under intraperitoneal (ip) S(+)-ketamine, 20 male Wistar rats were divided into two groups (n=10): maintenance with iv S(+)-ketamine or dex (keta and dex groups), and submitted to right (R) nephrectomy and left (L) renal artery clamping for 45 min. Blood creatinine was measured before ischemia (T1) and 48h after reperfusion (T2), when L nephrectomy was performed. Histological analysis was performed in all kidneys. RESULTS: Blood creatinine was significantly higher at T2 in both groups, but dex group results were lower than those of keta group. Histological changes: between groups, R kidneys did not differ; there were significant high scores for vascular dilation: keta L kidneys; for vascular congestion, tubular dilation, and necrosis: L kidneys from both groups; for tubular degeneration: keta R kidneys. CONCLUSION: S(+)-ketamine plus IRI were aggressive to rat kidneys, according to histological changes, and dexmedetomidine may have not totally protected the kidneys from these injuries, despite the better results of blood creatinine.

Biomarcadores renais de lesão glomerular e tubular em pacientes submetidos à cirurgia arterial / Biomarkers of renal glomerular and tubular injuries in patients anesthetized for arterial surgery

Objetivos: Estudar a função renal de pacientes arteriopatas submetidos a cirurgia vascular, avaliando a concordância entre as estimativas do ritmo de filtração glomerular (RFG) obtidos pela aferição da creatinina e cistatina C plasmática, verificando se diabetes, hipertensão e função renal pré-operatórias apresentam relação com função tubular no pós-operatório e investigando a possível influência da hemodiluição na avaliação da função renal por meio da cistatina C. Casuística e métodos: Trata-se de estudo de coorte, prospectivo, incluindo 144 pacientes consecutivos submetidos à anestesia para cirurgia arterial e distribuídos em 4 grupos, sendo (GDH), diabéticos e hipertensos, (GD), diabéticos, (GH), hipertensos e (GN), sem hipertensão ou diabetes. Foram obtidos urina para dosagens laboratoriais de creatinina urinária (Ucr) (mmol , fosfatase alcalina (FA) (U , -glutamiltransferase ( GT) (U e sangue para dosagem de albumina (g/dL), globulina (g/dL) uréia (mg/dL), creatinina (mg/dL), cistatina C (mg/L) e aferida a osmolaridade plasmática (mOsm/L) no pré-operatórios (M1) e após 24 horas do término da cirurgia (M2). As estimativas do RFG foram comparadas pelo método de Bland-Altman...

Objective: The aim of this study was to study the renal function of patients submitted to anaesthesia for arterial surgery, evaluating the agreement between GFR equations by cystatin C and creatinine, checking whether preoperative diabetes, hypertension, and renal function had any relationship with postoperative tubule function, and investigating possible hemodilution influence in cystatin C GFR based equations. Casuistry and Methods: Prospective cohort study including 144 patients submitted to anaesthesia for arterial surgery enrolled consecutively and divided into four groups: (GDH), diabetes and hypertension, (GD), diabetes, (GH), hypertension, and (GN), without hypertension or diabetes. Urine was obtained for laboratory analysis of urinary creatinine (Ucr) (mmol , alkaline phosphatase (AP) (U , -glutamyltransferase ( GT) (U , and blood for albumin (g/dL), globulin (g/dL), urea (mg /dL), creatinine (mg /dL), cystatin C (mg/L), and the plasma osmolarity (mOsm/L), before (M1) and 24h after the end of surgery (M2). Bland and Altman analysis was used to assessing agreement between two methods of GFR of measurements...

Patient perceptions about anesthesia and anesthesiologists before and after surgical procedures / Percepção do paciente sobre a anestesia e o anestesiologista antes e depois do procedimento cirúrgico

CONTEXT AND OBJECTIVE: Anesthesiologist-patient relationships are established preoperatively and intraoperatively. These are opportunities for providing correct information about anesthesia/anesthesiologists, thereby improving outcomes. The aim here was to evaluate patients' perceptions about anesthesiologists before anesthesia and to identify whether the anesthetic care would change such perceptions. DESIGN AND SETTING: Prospective cross-sectional study using data obtained in 2007-2008, at a tertiary university hospital. METHODS: 518 patients aged 16 years or over were interviewed before and after anesthesia exposure. A questionnaire was used to determine patient characteristics and perceptions of anesthesia/anesthesiologists. RESULTS: The patients were 16-89 years of age and 59.8 percent had attended elementary school. 79.1 percent said that anesthesiologists were specialized physicians. Anesthesiologists' roles were associated with loss of consciousness (35.5 percent pre-anesthesia; 43.5 percent post-anesthesia), pain relief (29.7 percent pre-anesthesia, 31.7 percent post-anesthesia), vital sign monitoring (17.6 percent pre-anesthesia, 35 percent post-anesthesia; P < 0.05); and drug administration (10.8 percent pre-anesthesia, 43.9 percent post-anesthesia; P < 0.05). The level of confidence in the physician was rated high (82.2 percent and 89.8 percent pre- and post-anesthesia, respectively; P < 0.05) or intermediate (5.8 percent and 6.6 percent pre- and post-anesthesia, respectively; P < 0.05). The care provided by anesthesiologists was classified as: elucidating (52.8 percent), encouraging (52.6 percent), neutral (10.2 percent) and careless (0.8 percent). CONCLUSION: Patients' perceptions of anesthesiologists' roles were fairly good, but improvements in this relationship still need to be pursued, to achieve better outcomes. Anesthetic care was important in providing information, confidence and reassurance among patients, regarding their perceptions. Anesthesiologists should not miss opportunities to provide excellent professional care for patients, thereby improving anesthesia outcomes and their image.

CONTEXTO E OBJETIVO: A relação anestesiologista-paciente é estabelecida no pré-operatório e intraoperatório, oportunidades que proporcionam informações corretas sobre anestesia/anestesiologista, melhorando seus resultados. O objetivo foi avaliar a percepção dos pacientes sobre o anestesiologista antes da anestesia e se os cuidados anestésicos poderiam mudar essa percepção. TIPO DE ESTUDO E LOCAL: Estudo prospectivo transversal com dados em 2007-2008, em hospital universitário terciário. MÉTODOS: Foram entrevistados 518 pacientes com 16 anos ou mais antes e depois da exposição à anestesia. Um questionário determinou as características do paciente e da percepção da anestesia/anestesiologista. RESULTADOS: Os pacientes tinham entre 16 e 89 anos e 59,8 por cento possuíam ensino fundamental, 79,1 por cento responderam que o anestesiologista é um médico especializado. O papel do anestesiologista foi associado à perda de consciência (35,5 por cento pré-anestesia, 43,5 por cento pós-anestesia), alívio de dor (29,7 por cento pré-anestesia, 31,7 por cento pós-anestesia), monitorização dos sinais vitais (17,6 por cento pré-anestesia, 35 por cento pós-anestesia; P < 0,05), e administração de medicamentos (10,8 por cento pré-anestesia, 43,9 por cento pós-anestesia; P < 0,05). O nível de confiança no médico foi considerado alto (82,2 por cento e 89,8 por cento no pré e pós-anestesia, respectivamente, P < 0,05) ou intermediário (5,8 por cento e 6,6 por cento no pré e pós-anestesia, respectivamente, P < 0,05). A assistência prestada pelo anestesiologista foi classificada como: elucidativa (52,8 por cento), encorajadora (52,6 por cento), indiferente (10,2 por cento) e displicente (0,8 por cento). CONCLUSÃO: A percepção sobre o papel do anestesiologista foi satisfatória, mas as melhorias nessa relação ainda são necessárias para se conseguirem melhores resultados. O atendimento anestésico foi importante para a informação, confiança e segurança do paciente sobre essa percepção. O anestesiologista não deve perder oportunidades de exercer excelentes cuidados profissionais para os pacientes, melhorando os resultados de sua anestesia e sua imagem.

The epidemiologic paradox of low birth weight in Brazil / O paradoxo epidemiológico do baixo peso ao nascer no Brasil / La paradoja epidemiológica del bajo peso al nacer en Brasil

OBJECTIVE: To examine whether the low birth weight (LBW) paradox exists in Brazil. METHODS: LBW and cesarean section rates between 1995 and 2007 were estimated based on data from SINASC (Brazilian Live Births Database). Infant mortality rates (IMRs) were obtained using an indirect method that correct for underreporting. Schooling information was obtained from census data. Trends in LBW rate were assessed using joinpoint regression models. The correlations between LBW rate and other indicators were graphically assessed by lowess regression and tested using Spearman's rank correlation. RESULTS: In Brazil, LBW rate trends were non-linear and non-significant: the rate dropped from 7.9 percent in 1995 to 7.7 percent in 2000, then increased to 8.2 percent in 2003 and remained nearly steady thereafter at 8.2 percent in 2007. However, trends varied among Brazilian regions: there were significant increases in the North from 1999 to 2003 (2.7 percent per year), and in the South (1.0 percent per year) and Central-West regions (0.6 percent per year) from 1995 to 2007. For the entire period studied, higher LBW and lower IMRs were seen in more developed compared to less developed regions. In Brazilian States, in 2005, the higher the IMR rate, the lower the LBW rate (p=0.009); the lower the low schooling rate, the lower the LBW rate (p=0.007); the higher the number of neonatal intensive care beds per 1,000 live births, the higher the LBW rate (p=0.036). CONCLUSIONS: The low birth weight paradox was seen in Brazil. LBW rate is increasing in some Brazilian regions. Regional differences in LBW rate seem to be more associated to availability of perinatal care services than underlying social conditions.

OBJETIVO: Identificar a presença do paradoxo do baixo peso ao nascer (BPN) no Brasil. MÉTODOS: As taxas de BPN e de cesárea, de 1995 a 2007, foram estimadas a partir do Sistema de Informações sobre Nascidos Vivos. As taxas de mortalidade infantil, foram calculadas por métodos indiretos, com correção para sub-registro. A taxa de escolaridade foi obtida de dados censitários. As tendências da taxa de BPN foram avaliadas utilizando-se modelos de regressão joinpoint. As associações entre a taxa de BPN com outros indicadores foram avaliadas por regressão lowess e correlação de Spearman. RESULTADOS: No Brasil, as tendências da taxa de BPN foram não lineares e não significantes: a taxa caiu de 7,9 por cento em 1995 para 7,7 por cento em 2000, aumentando para 8,2 por cento em 2003 e permanecendo estável em 8,2 por cento em 2007. Entretanto, as tendências variaram nas regiões brasileiras: houve aumentos significantes no Norte (2,7 por cento por ano), de 1999 a 2003, e no Sul (1,0 por cento por ano) e Centro-Oeste (0,6 por cento por ano), de 1995 a 2007. As taxas de BPN foram mais altas e as taxas de mortalidade infantil mais baixas nas regiões mais desenvolvidas do que nas menos desenvolvidas. Em 2005, quanto mais elevada a taxa de mortalidade infantil, menor foi a taxa de BPN (p = 0,009); quanto mais alta a taxa de baixa escolaridade, menor foi a taxa de BPN (p = 0,007); quanto maior o número de leitos de terapia intensiva neonatal por 1.000 nascidos vivos, mais elevada foi a taxa de BPN (p = 0,036). CONCLUSÕES: O paradoxo do BPN foi detectado no Brasil. A taxa de BPN está aumentando em algumas regiões brasileiras. Diferenças regionais na taxa de BPN parecem estar mais relacionadas à disponibilidade de assistência perinatal do que às condições sociais.

OBJETIVO: Identificar la presencia de la paradoja de bajo peso al nacer (BPN) en Brasil. MÉTODOS: Las tasas de BPN y de cesárea, de 1995 a 2007, fueron estimadas a partir del Sistema de Informaciones sobre Nacidos Vivos. Las tasas de mortalidad infantil fueron calculadas por métodos indirectos, con corrección para subregistro. La tasa de escolaridad fue obtenida de datos de censos. Las tendencias de la tasa de bajo peso al nacer fueron evaluadas utilizándose modelos de regresión joinpoint. Las asociaciones entre la tasa de bajo peso al nacer con otros indicadores fueron evaluadas por regresión lowess y correlación de Spearman. RESULTADOS: En Brasil, las tendencias en la tasa de BPN fueron no lineares y no significativas: la tasa disminuyó de 7,9 por ciento en 1995 a 7,7 por ciento en 2000, aumentando a 8,2 por ciento en 2003, y permaneciendo estable en 8,2 por ciento en 2007. Mientras, las tendencias variaron en las regiones brasileras: hubo aumentos significativos en el Norte (2,7 por ciento por año), de 1999 a 2003, y en el Sur (1,0 por ciento por año) y Centro-Oeste (0,6 por ciento por año), de 1995 a 2007. Las tasas de BPN fueron más altas y las tasas de mortalidad infantil más bajas en las regiones más desarrolladas en comparación con las menos desarrolladas. En 2005, cuanto más elevada la tasa de mortalidad infantil, menor fue la tasa de BPN (p=0,009); cuanto más alta la tasa de baja escolaridad, menor la tasa de BPN (p=0,007); cuanto mayor el número de lechos de terapia intensiva neonatal por 1000 nacidos vivos, más elevada la tasa de BPN (p=0,036). CONCLUSIONES: La paradoja del BPN fue detectado en Brasil. La tasa de BPN está aumentando en algunas regiones brasileras. Diferencias regionales en la tasa de BPN parecen estar más relacionadas con la disponibilidad de asistencia perinatal que con las condiciones sociales.

The epidemiologic paradox of low birth weight in Brazil.

OBJECTIVE: To examine whether the low birth weight (LBW) paradox exists in Brazil. METHODS: LBW and cesarean section rates between 1995 and 2007 were estimated based on data from SINASC (Brazilian Live Births Database). Infant mortality rates (IMRs) were obtained using an indirect method that correct for underreporting. Schooling information was obtained from census data. Trends in LBW rate were assessed using joinpoint regression models. The correlations between LBW rate and other indicators were graphically assessed by lowess regression and tested using Spearman's rank correlation. RESULTS: In Brazil, LBW rate trends were non-linear and non-significant: the rate dropped from 7.9% in 1995 to 7.7% in 2000, then increased to 8.2% in 2003 and remained nearly steady thereafter at 8.2% in 2007. However, trends varied among Brazilian regions: there were significant increases in the North from 1999 to 2003 (2.7% per year), and in the South (1.0% per year) and Central-West regions (0.6% per year) from 1995 to 2007. For the entire period studied, higher LBW and lower IMRs were seen in more developed compared to less developed regions. In Brazilian States, in 2005, the higher the IMR rate, the lower the LBW rate (p=0.009); the lower the low schooling rate, the lower the LBW rate (p=0.007); the higher the number of neonatal intensive care beds per 1,000 live births, the higher the LBW rate (p=0.036). CONCLUSIONS: The low birth weight paradox was seen in Brazil. LBW rate is increasing in some Brazilian regions. Regional differences in LBW rate seem to be more associated to availability of perinatal care services than underlying social conditions.

Emergence agitation in pediatric anesthesia: current features.

OBJECTIVE: Postoperative agitation in children is a well-documented clinical phenomenon with incidence ranging from 10% to 67%. There is no definitive explanation for this agitation. Possible causes include rapid awakening in unfamiliar settings, pain (wounds, sore throat, bladder distension, etc.), stress during induction, hypoxemia, airway obstruction, noisy environment, anesthesia duration, child's personality, premedication and type of anesthesia. The purpose of this paper is to discuss the possible causes of postoperative agitation in children, providing a foundation for better methods of identifying and preventing this problem. SOURCES: MEDLINE and PubMed were searched using the following words: emergence, agitation, incidence, etiology, diagnosis, treatment, children, pediatric, anesthesia. SUMMARY OF THE FINDINGS: This study includes a review of potential agitation trigger factors and a proposal for a standardized diagnostic score system, in addition to measures to improve prevention and treatment. CONCLUSION: No single factor can identified as the cause of postoperative agitation, which should therefore be considered a syndrome made up of biological, pharmacological, psychological and social components, and which anesthesiologists and pediatric intensive care specialists should be prepared to identify, prevent and intervene appropriately as necessary.