The Quality of Recovery after Dexamethasone, Ondansetron, or Placebo Administration in Patients Undergoing Lower Limbs Orthopedic Surgery under Spinal Anesthesia Using Intrathecal Morphine. A Randomized Controlled Trial.

Intrathecal morphine is widely and successfully used to prevent postoperative pain after orthopedic surgery, but it is frequently associated with side effects. The aim of this study was to evaluate the effect of dexamethasone or ondansetron when compared to placebo to reduce the occurrence of these undesirable effects and, consequently, to improve the quality of recovery based on patient's perspective. Methods. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline. On the morning following surgery, a quality of recovery questionnaire (QoR-40) was completed. Results. No differences were detected in the global and dimensional QoR-40 scores following surgery; however, following postanesthesia care unit (PACU) discharge, pain scores were higher in patients receiving ondansetron compared with patients who received dexamethasone. Conclusion. Neither ondansetron nor dexamethasone improves the quality of recovery after lower limbs orthopedic surgery under spinal anesthesia using intrathecal morphine.

[Amaurosis and contralateral cranial nerve pairs III and VI paralysis after peribulbar block - case report]. / Amaurose e paralisia do III e do VI pares cranianos contralaterais após bloqueio peribulbar ­ relato de caso.

BACKGROUND AND OBJECTIVES: Peribulbar anesthesia has emerged as a safer option compared with intraconal retrobulbar block. Still, peribulbar anesthesia may not be considered without risk. Numerous complications have been described when performing this technique. This report aims to describe a rare case of amaurosis and contralateral paralysis while attempting to perform a peribulbar anesthesia. CASE REPORT: Male patient, 75-year old, physical status ASA II, undergoing cataract surgery by phacoemulsification with intraocular lens implantation. Sedated with fentanyl and midazolam and subjected to peribulbar anesthesia. There were no complications during surgery. After finishing the procedure, the patient reported lack of vision in the contralateral eye. Akinesia of the muscles innervated by the cranial nerve pairs III and VI, ptosis, and medium-sized pupils unresponsive to light stimulus were observed. Four hours after anesthesia, complete recovery of vision and eyelid and eyeball movements was seen in the non-operated eye. CONCLUSIONS: During peribulbar anesthesia, structures located in the intraconal space can be accidentally hit leading to complications such as described in the above report. Following the technical guidelines and using appropriate size needles may reduce the risk of such complication, but not completely.

Quality of recovery from anesthesia in patients undergoing orthopedic surgery of the lower limbs / Qualidade da recuperação da anestesia em pacientes submetidos à cirurgia ortopédica em membros inferiores

Abstract Background and objectives: For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. Methods: We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score—between 40 and 200—was used to determine the quality of recovery and identify the potential predictors. Results: We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40 ≤ 195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. Conclusion: Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument.

Resumo Justificativa e objetivos: Para os pacientes submetidos à anestesia regional para cirurgias ortopédicas, situação comum em nosso meio, a qualidade da recuperação pode ser influenciada de diversas formas, o que justifica a determinação de possíveis fatores preditivos de insatisfação. O objetivo do estudo foi avaliar a opinião dos pacientes sobre a recuperação da anestesia para cirurgias ortopédicas em membros inferiores. Também foram identificados possíveis fatores preditivos para baixa qualidade da recuperação. Métodos: Foram avaliados os pacientes submetidos à cirurgia ortopédica nos membros inferiores e aptos a participar do estudo. Os dados relacionados à cirurgia, à anestesia, às possíveis complicações na sala de recuperação pós-anestésica (SRPA) e na enfermaria foram registrados. Na manhã seguinte à cirurgia, os pacientes foram avaliados por um estudante de medicina que aplicou o questionário QoR-40. A pontuação obtida, entre 40 a 200, foi usada para determinar a qualidade da recuperação e identificar os possíveis fatores preditivos. Resultados: Foram avaliados 172 pacientes. O escore médio do questionário foi de 192 pontos. A chance de ocorrência de valores menores de QoR-40 foi 2 vezes maior entre os pacientes do sexo masculino. Pacientes que permaneceram sob sedação classificada como maior ou igual a 4 segundo a escala proposta por Ramsay apresentaram risco 3,5 vezes maior de apresentar menor pontuação no QoR-40 quando comparados com aqueles que permaneceram com nível de sedação 1 ou 2. Em relação à dor, a cada incremento de uma unidade na escala numérica (0 a 10), houve um aumento de 19% no risco para QoR-40 ≤ 195. Da mesma forma, o risco para pontuação abaixo da mediana foi 2,3 vezes maior entre aqueles que apresentaram náuseas e/ou vômitos na enfermaria. Conclusão: O sexo masculino, a náusea, o vômito, a dor durante a permanência na enfermaria e níveis mais profundos de sedação são possíveis fatores preditivos para menor pontuação segundo o instrumento adotado.

Quality of recovery from anesthesia in patients undergoing orthopedic surgery of the lower limbs.

BACKGROUND AND OBJECTIVES: For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. METHODS: We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score-between 40 and 200-was used to determine the quality of recovery and identify the potential predictors. RESULTS: We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40≤195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. CONCLUSION: Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument.

[Quality of recovery from anesthesia in patients undergoing orthopedic surgery of the lower limbs]. / Qualidade da recuperação da anestesia em pacientes submetidos à cirurgia ortopédica em membros inferiores.

BACKGROUND AND OBJECTIVES: For patients undergoing regional anesthesia for orthopedic surgery, a common situation in our work environment, the quality of recovery may be influenced in different ways, which justifies studies to identify possible predictive factors of dissatisfaction. The aim of this study was to assess the opinion of patients on recovery from anesthesia for lower limb orthopedic surgeries. We also identified potential predictive factors for poor quality of recovery. METHODS: We evaluated patients undergoing lower limb orthopedic surgeries and able to participate in the study. Data related to surgery, anesthesia, possible complications in the post-anesthetic care unit (PACU) and in the ward were recorded. In the morning after surgery, patients were evaluated by a medical student who applied the QoR-40 questionnaire. The resulted score-between 40 and 200-was used to determine the quality of recovery and identify the potential predictors. RESULTS: We evaluated 172 patients. The questionnaire average score was 192 points. The chance to have lower scores in the QoR-40 was two times higher among males. Patients who remained under sedation, classified as greater than or equal to 4 on the scale proposed by Ramsay, had a 3.5 times higher risk of having lower scores in the QoR-40 compared to those who remained with level 1 or 2 of sedation. Regarding pain, at every increase of one unit in the numerical scale (0-10), there was a 19% increase in risk for QoR-40 ≤ 195. Similarly, the risk for a score below the median was 2.3 times higher among those presenting with nausea and/or vomiting in the ward. CONCLUSION: Male, nausea, vomiting, pain while in the ward, and deeper levels of sedation are possible predictive factors for lower scores according to the adopted instrument.

"Loss of breath" as a cause of postoperative hypoxia and bradycardia in children submitted to tonsillectomy / "Perda de fôlego" como causa de hipóxia e bradicardia pós-operatória em criança submetida à amigdalectomia

ABSTRACTBACKGROUND AND OBJECTIVES: the "shortness of breath" or "breathing interruption" crisis can be considered a cause of hypoxia in childhood. It is characterized by the presence of a triggering factor followed by weeping and apnea in expiration accompanied by cyanosis or pallor. The sequence of events may include bradycardia, loss of consciousness, abnormal postural tone and even asystole. A review of the literature revealed only two reports of postoperative apnea caused by "shortness of breath".CASE REPORT: this article describes the case of a child with a history of "shortness of breath" undiagnosed before the adenotonsillectomy, but that represented the cause of episodes of hypoxemia and bradycardia in the postoperative period.CONCLUSIONS: the "shortness of breath" crisis should be considered as a possible cause of perioperative hypoxia in children, especially when there is a history suggestive of this problem. As some events may be accompanied by bradycardia, loss of consciousness, abnormal postural tone and even asystole, observation in a hospital setting should be considered.

RESUMOJUSTIFICATIVA E OBJETIVOS: A crise de "perda de fôlego" ou de "interrupção respiratória" pode ser considerada uma causa de hipóxia na infância. É caracteriza pela presença de um fator desencadeante seguido por choro e apneia em expiração acompanhada de cianose ou palidez cutânea. A sequência de eventos pode incluir bradicardia, perda da consciência, alteração do tônus postural e até assistolia. Uma revisão da literatura evidenciou apenas dois relatos de apneia pós-operatória causada por "perda de fôlego".RELATO DO CASO: O presente artigo descreve um caso de criança com antecedente de crises de "perda de fôlego" não diagnosticadas antes da feitura de adenoamigdalectomia, mas que representaram a causa de episódios de hipoxemia e bradicardia no período pós-operatório.CONCLUSÕES: As crises de "perda de fôlego" devem ser consideradas como possível causa de hipóxia perioperatória em crianças, principalmente quando há história prévia sugestiva. Como alguns eventos podem ser acompanhados de bradicardia, perda da consciência, alteração do tônus postural e até assistolia, a observação em ambiente hospitalar deve ser considerada.

["Loss of breath" as a cause of postoperative hypoxia and bradycardia in children submitted to tonsillectomy]. / "Perda de fôlego" como causa de hipóxia e bradicardia pós-operatória em criança submetida à amigdalectomia.

BACKGROUND AND OBJECTIVES: The "shortness of breath" or "breathing interruption" crisis can be considered a cause of hypoxia in childhood. It is characterized by the presence of a triggering factor followed by weeping and apnea in expiration accompanied by cyanosis or pallor. The sequence of events may include bradycardia, loss of consciousness, abnormal postural toneand even asystole. A review of the literature revealed only two reports of postoperative apneacaused by "shortness of breath". CASE REPORT: This article describes the case of a child with a history of "shortness of breath" undiagnosed before the adenotonsillectomy, but that represented the cause of episodes of hypoxemia and bradycardia in the postoperative period. CONCLUSIONS: the "shortness of breath" crisis should be considered as a possible cause of perioperative hypoxia in children, especially when there is a history suggestive of this problem. As some events may be accompanied by bradycardia, loss of consciousness, abnormal postural tone and even asystole, observation in a hospital setting should be considered.

"Loss of breath" as a cause of postoperative hypoxia and bradycardia in children submitted to tonsillectomy.

BACKGROUND AND OBJECTIVES: the "shortness of breath" or "breathing interruption" crisis can be considered a cause of hypoxia in childhood. It is characterized by the presence of a triggering factor followed by weeping and apnea in expiration accompanied by cyanosis or pallor. The sequence of events may include bradycardia, loss of consciousness, abnormal postural tone and even asystole. A review of the literature revealed only two reports of postoperative apnea caused by "shortness of breath". CASE REPORT: this article describes the case of a child with a history of "shortness of breath" undiagnosed before the adenotonsillectomy, but that represented the cause of episodes of hypoxemia and bradycardia in the postoperative period. CONCLUSIONS: the "shortness of breath" crisis should be considered as a possible cause of perioperative hypoxia in children, especially when there is a history suggestive of this problem. As some events may be accompanied by bradycardia, loss of consciousness, abnormal postural tone and even asystole, observation in a hospital setting should be considered.

Ocorrência da agitação no despertar em crianças anestesiadas com isoflurano ou sevoflurano: influência do tratamento com a dexmedetomidina / Agitation at awakening in children anesthetized with isoflurane or sevoflurane: influence of treatment with dexmedetomidine

A agitação ao despertar tem sido descrita como um fenômeno comum em crianças anestesiadas com agentes inalatórios. Apesar do sevoflurano e do desflurano serem os agentes mais comumente associados a essa complicação, ainda não está claro se a incidência da agitação é menor com o emprego do isoflurano. Diferentes agentes têm sido empregados para reduzir a probabilidade de ocorrência da agitação ao despertar. A dexmedetomidina, um agente α2-agonista altamente seletivo, parece reduzir a incidência dessa complicação após anestesia com sevoflurano ou desflurano. No entanto, ainda não se avaliou os efeitos da administração desse agente em crianças submetidas à anestesia com isoflurano. O presente estudo teve como objetivo testar a hipótese de que a incidência de agitação ao despertar é maior em crianças anestesiadas com o sevoflurano quando comparada àquela observada após a anestesia com o isoflurano, segundo a aplicação de uma escala validada e com confiabilidade comprovada (Pediatric Anesthesia Emergence Delirium - PAED) aplicada na sala de recuperação pósanestésica (SRPA). Também foi avaliada a hipótese de que a administração da dexmedetomidina antes do fim da anestesia reduz a incidência dessa complicação. Realizou-se ensaio clínico, comparativo, randomizado, duplo cego e controlado. Foram estudadas 140 crianças, com idade entre 2 e 12 anos, submetidas à amigdalectomia, associada ou não à adenoidectomia, sob anestesia geral. As crianças foram distribuídas, de forma aleatória, em quatro grupos de estudo de acordo com o anestésico inalatório empregado para a manutenção da anestesia e pela administração ou não da dexmedetomidina no final da cirurgia: Grupo S (n=35) – Sevoflurano e solução fisiológica; Grupo SD (n=35) – Sevoflurano e dexmedetomidina 0,5 μg.kg-1; Grupo I (n=35) Isovoflurano e solução fisiológica; Grupo ID (n=35) - Isovoflurano e dexmedetomidina 5 miug.kg-1...

Main concerns of patients regarding the most common complications in the post-anesthetic care unit.

BACKGROUND AND OBJECTIVES: 'Minor' events have a fundamental role in the determination of the quality of the Anesthesiology service. The objective of the present study was to evaluate the main concerns of patients regarding the post-anesthetic period and to test the hypothesis that the most undesirable effects can be influenced by demographic characteristics. METHODS: Four hundred and forty patients answered a questionnaire immediately before the pre-anesthetic evaluation. Possible undesirable effects in the immediate postoperative period, based on data gathered in the literature considering the criterion of frequency but not severity were listed. Demographic data and the nine more frequent occupations were evaluated. The information gathered from the analysis of the questionnaires was related with anthropometric, socioeconomic, and educational data of the patients to assess their influence on the answer profile. RESULTS: Among the undesirable effects, the fear of being intubated upon waking up was mentioned more often as the most important factor, followed by 'severe pain at the surgery site'. Analysis of the three most frequent undesirable effects according to the demographic data did not show significant statistical differences, except for 'pain at the surgery site' (which was less common among male patients). CONCLUSIONS: The main post-anesthetic concerns of patients included: waking up with a tube in the throat, severe pain at the surgery site, and remembering being conscious during the surgery. Age, schooling, and family income did not determine differences in the concerns of patients.

Principais preocupações dos pacientes sobre as complicações mais frequentes na sala de recuperação pós-anestésica / Principales preocupaciones de los pacientes sobre las complicaciones más frecuentes en la sala de recuperación postanestésica / Main concerns of patients regarding the most common complications in the post-anesthetic care unit

Justificativa e objetivos: Eventos considerados "menores" têm assumido papel fundamental na determinação da qualidade do serviço prestado na área da Anestesiologia. O objetivo do presente estudo foi avaliar as principais preocupações dos pacientes em relação ao período pós-anestésico e testar a hipótese de que os efeitos mais indesejados podem ser influenciados...

Background and objectives: "Minor" events have a fundamental role in the determination of the quality of the Anesthesiology service. The objective of the present study was to evaluate the main concerns of patients regarding the post-anesthetic period and to test the hypothesis that the most undesirable effects can be influenced...

Justificativa y objetivos: Los eventos considerados "menores", han asumido un rol fundamental en la determinación de la calidad del servicio prestado en el área de la Anestesiología. El objetivo del presente estudio, fue evaluar las principales preocupaciones de los pacientes con relación al período postanestésico y comprobar la hipótesis de que los efectos menos deseados pueden sufrir el influjo...

Intubação nasotraqueal guiada por rinoscópio em criança de um ano de idade portadora de Osteogenesis imperfecta: relato de caso / Intubación nasotraqueal guiada por rinoscopio en niño de un año de edad portador de Osteogenesis imperfecta: relato de caso / Rhinoscope-guided nasotracheal intubation in a one-year old child with Osteogenesis imperfecta: case report

JUSTIFICATIVA E OBJETIVOS: A Osteogênesis Imperfecta (OI) é uma rara doença genética de herança autossômica dominante. A anestesia para o paciente portador da OI inclui diversos desafios, entre eles o manuseio da via aérea e a escolha da técnica anestésica. O objetivo do presente artigo foi descrever caso de criança portadora desta doença associada à hidrocefalia, submetida à anestesia venosa total e intubação nasotraqueal guiada por rinoscópio para realização de derivação ventrículo-peritoneal. RELATO DO CASO: Paciente do sexo masculino, um ano e três meses de idade, com diagnósticos de OI (tipo III) e hidrocefalia submetido à derivação ventrículo-peritoneal. Após a administração de midazolam (1 mg.kg-1) por via oral 30 minutos antes do procedimento, a criança foi monitorizada, seguindo-se a venóclise com cateter 24G. Após oxigenação, procedeu-se à indução anestésica com remifentanil, propofol e cisatracúrio. A intubação nasotraqueal foi guiada por rinolaringoscópio (Olimpus® ENF P3) e cânula de 4,5 mm com balonete foi inserida sem intercorrências. A anestesia foi mantida com infusão de remifentanil e propofol. A operação teve duração de 120 minutos, sem intercorrências. CONCLUSÕES: O presente relato descreveu alternativa de aces-so à via aérea em crianças submetidas à anestesia geral e que por algum motivo não podem ser ventiladas através da máscara laríngea. O rinolaringoscópio, por apresentar diâmetro reduzido, permite a inserção de cânulas traqueais que não poderiam ser utilizadas com o emprego do fibroscópio convencional.

BACKGROUND AND OBJECTIVES: Osteogenesis imperfecta (OI) is a rare, autosomal dominant disease. Anesthesia for patients with OI has several challenges; among them, management of the airways and the choice of anesthetic technique should be mentioned. The objective of this report was to describe the case of a child with this disorder associated with hydrocephalus who underwent total intravenous anesthesia and rhinoscope-guided nasotracheal intubation for a ventriculoperitoneal shunt. CASE REPORT: This is a 15-month old male with OI (type III) and hydrocephalus who underwent placement of a ventriculoperitoneal shunt. After the oral administration of midazolam (1 mg.kg-1) 30 minutes before the procedure, the child was monitored and, afterwards, a 24G catheter was used for venipuncture. After oxygenation, anesthesia was induced with remifentanil, propofol, and cisatracurium. A 4.5-mm ETT with balloon was used for the rhinoscopeguided (Olimpus® ENF P3) nasotracheal intubation without intercurrences. Anesthesia was maintained with the infusion of remifentanil and propofol. The surgery lasted 120 minutes, without intercurrences. CONCLUSIONS: The present report described an alternative for the access of the upper airways in children undergoing general anesthesia and who, for some reason, cannot be ventilated with a laryngeal mask. Since the rhinolaryngoscope has a reduced diameter, it allows the insertion of ETTs that could not be used with conventional fiberscopes.

JUSTIFICATIVA Y OBJETIVOS: La Osteogénesis Imperfecta (OI) es una rara enfermedad genética de herencia autosómica dominante. La anestesia para el paciente portador de la OI incluye diversos retos, entre ellos el manejo de la vía aérea y la elección de la técnica anestésica. El objetivo del presente artículo, fue describir el caso de un niño portador de esa enfermedad asociada a la hidrocefalia, y sometido a la anestesia venosa total e intubación nasotraqueal, guiada por rinoscopio para la realización de la derivación ventrículo-peritoneal. RELATO DEL CASO: Paciente del sexo masculino, un año y tres meses de edad, con diagnósticos de OI (tipo III) e hidrocefalia sometido a la derivación ventrículo-peritoneal. Después de la administración de midazolam (1 mg.kg-1) por vía oral, 30 minutos antes del procedimiento, el niño fue monitorizado, con posterior venoclisis con catéter 24G. Después de la oxigenación, se procedió a la inducción anestésica con remifentanil, propofol y cisatracurio. La intubación nasotraqueal fue guiada por rinolaringoscopio (Olimpus® ENF P3) y cánula de 4,5 mm con balón e insertada sin intercurrencias. La anestesia se mantuvo con infusión de remifentanil y propofol. La operación duró 120 minutos sin intercurrencias. CONCLUSIONES: El presente relato describió una alternativa de acceso a la vía aérea en niños sometidos a la anestesia general y que por algún motivo no pueden ser ventilados a través de la máscara laríngea. El rinolaringoscopio, por presentar un diámetro reducido, permite la inserción de cánulas traqueales que no podrían ser utilizadas con el uso del fibroscopio convencional.

[Rhinoscope-guided nasotracheal intubation in a one-year old child with Osteogenesis imperfecta: case report]. / Intubação nasotraqueal guiada por rinoscópio em criança de um ano de idade portadora de Osteogenesis imperfecta: relato de caso.

BACKGROUND AND OBJECTIVES: Osteogenesis imperfecta (OI) is a rare, autosomal dominant disease. Anesthesia for patients with OI has several challenges; among them, management of the airways and the choice of anesthetic technique should be mentioned. The objective of this report was to describe the case of a child with this disorder associated with hydrocephalus who underwent total intravenous anesthesia and rhinoscope-guided nasotracheal intubation for a ventriculoperitoneal shunt. CASE REPORT: This is a 15-month old male with OI (type III) and hydrocephalus who underwent placement of a ventriculoperitoneal shunt. After the oral administration of midazolam (1 mg.kg-1) 30 minutes before the procedure, the child was monitored and, afterwards, a 24G catheter was used for venipuncture. After oxygenation, anesthesia was induced with remifentanil, propofol, and cisatracurium. A 4.5-mm ETT with balloon was used for the rhinoscopeguided (Olimpus) ENF P3) nasotracheal intubation without intercurrences. Anesthesia was maintained with the infusion of remifentanil and propofol. The surgery lasted 120 minutes, without intercurrences. CONCLUSIONS: The present report described an alternative for the access of the upper airways in children undergoing general anesthesia and who, for some reason, cannot be ventilated with a laryngeal mask. Since the rhinolaryngoscope has a reduced diameter, it allows the insertion of ETTs that could not be used with conventional fiberscopes.

[Subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt: case report]. / Anestesia subaracnoidea para cesariana em paciente com derivação ventriculoperitoneal: relato de caso.

BACKGROUND AND OBJECTIVES: Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT: This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5% hyperbaric bupivacaine and 80 (1/4)g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS: The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

Anestesia subaracnoidea para cesariana em paciente com derivação ventriculoperitoneal: relato de caso / Anestesia subaracnoidea para cesárea en paciente con derivación ventriculoperitoneal: relato de caso / Subarachnoid blockade for cesarean section in a patient with ventriculoperitoneal shunt: case report

JUSTIFICATIVA E OBJETIVOS: Pacientes portadores de derivação ventriculoperitoneal (DVP) causam preocupação adicional quando o bloqueio do neuroeixo é indicado, sobretudo em obstetrícia. Atualmente não existe consenso na literatura sobre a técnica anestésica de escolha nesses casos. O objetivo deste relato foi descrever o caso de paciente com DVP submetida à cesariana sob anestesia subaracnoidea. RELATO DO CASO: Paciente de 28 anos, secundigesta, um parto anterior sem história de aborto, de termo, pré-natal sem intercorrências, em trabalho de parto há cinco horas, uma cesariana há sete anos. Evoluiu com sofrimento fetal agudo, indicada cesariana de emergência. Portadora DVP há cinco anos, devido à hipertensão intracraniana (sic) de etiologia desconhecida. Exame neurológico normal. Foi submetida à anestesia subaracnoidea com bupivacaína a 0,5 por cento pesada 15 mg e morfina 80 »g. Nascimento fetal com Apgar 8 (1 minuto) e 10 (5 minutos) após nascimento. Alta após dois dias em excelente condição clínica. CONCLUSÕES: A abordagem anestésica de pacientes obstétricas com DVP é complexa, devendo-se comparar o risco e o benefício das técnicas no momento e circunstância da indicação. O bloqueio do neuroeixo tem sido relatado com sucesso em portadoras de doenças neurológicas. Quanto à DVP, não existe na literatura contraindicação formal ao bloqueio. Os casos devem ser individualizados. Neste relato, diante da emergência obstétrica e do quadro neurológico vigente, optou-se pelo bloqueio no neuroeixo. A técnica proporcionou adequado manuseio da via aérea, boa condição materno-fetal e analgesia pós-operatória. A evolução foi favorável, sem alterações neurológicas decorrentes da técnica escolhida.

BACKGROUND AND OBJECTIVES: Patients with ventriculoperitoneal shunt (VPS) represent an additional concern when neuroaxis block is indicated, especially in obstetrics. Currently, a consensus on the anesthetic technique of choice in those cases does not exist in the literature. The objective of this report was to describe the case of a cesarean section under subarachnoid blockade in a patient with VPS. CASE REPORT: This is a 28 years old pregnant patient at term, in her second pregnancy, one prior delivery, a cesarean section seven years ago, no history of miscarriages, and pre-natal care without intercurrences, in labor for five hours. The patient evolved with acute fetal distress and an emergency cesarean section was indicated. She had had a VPS for five years due to intracranial hypertension (sic) of unknown etiology. Neurological exam was normal. She underwent subarachnoid block with 15 mg of 0.5 percent hyperbaric bupivacaine and 80 »g of morphine. The newborn had an Apgar of 8 (in the first minute) and 10 (in the 5th minute). The patient was discharged two days later in excellent clinical condition. CONCLUSIONS: The anesthetic approach of obstetric patients with VPS is complex, and the risk and benefits of anesthetic techniques, as well as the circumstances that led to this indication, should be considered at the time of the indication. Successful of neuroaxis block in patients with neurological diseases has been reported. As for VPS, formal contraindication for neuroaxis block does not exist in the literature. Cases should be individualized. In the present report, due to an obstetric emergency and the neurologic condition of the patient, a decision to use neuroaxis blockade was made. The technique provided adequate management of the airways, good maternal-fetal condition, and postoperative analgesia. The evolution was favorable and the patient did not show any neurologic changes secondary to the technique used.

JUSTIFICATIVA Y OBJETIVOS: Los pacientes portadores de derivación ventriculoperitoneal (DVP) nos causan una preocupación adicional cuando el bloqueo del neuro-eje está indicado, principalmente en obstetricia. Actualmente no existe un consenso en la literatura sobre la técnica anestésica de elección en esos casos. El objetivo de este relato, fue describir el caso de un paciente con DVP sometida a cesárea bajo anestesia subaracnoidea. RELATO DEL CASO: Paciente de 28 años, secundípara, con un parto anterior sin historial de aborto, de término, prenatal sin intercurrencias, en trabajo de parto hacía ya cinco horas, y una cesárea realizada hace siete años. Evoluciona con sufrimiento fetal agudo, indicada una cesárea de emergencia. Portadora DVP hace cinco años, debido a la hipertensión intracraneal (sic) de etiología desconocida. Examen neurológico normal. Se sometió a la anestesia subaracnoidea con bupivacaína a 0,5 por ciento pesada 15 mg y morfina 80 »g. El nacimiento fetal fue con Apgar 8 (1 minuto) y 10 (5 minutos) después del nacimiento. El alta fue concedida después de dos días en excelente condición clínica. CONCLUSIONES: El abordaje anestésico de pacientes obstétricas con DVP es complejo, y deben ser comparados el riesgo y el beneficio de las técnicas en el momento y en las circunstancias de la indicación. El bloqueo del neuro-eje ha sido relatado con éxito en las portadoras de enfermedades neurológicas. En cuanto a la DVP, no existe en la literatura ninguna contraindicación formal para el bloqueo. Los casos deben ser individualizados. En este relato frente a la emergencia obstétrica y el cuadro neurológico vigente, se optó por el bloqueo en el neuro-eje. La técnica proporcionó un adecuado manejo de la vía aérea, una buena condición materno-fetal y una analgesia postoperatoria. La evolución fue favorable sin alteraciones neurológicas provenientes de la técnica escogida.

[Tracheal intubation and the patient with a full stomach]. / Intubação traqueal e o paciente com o estômago cheio.

Pulmonary aspiration of gastric contents, despite its infrequent occurrence, demands special preventive care. Decreased oesophageal sphincter function and protective airway reflexes caused by depression of consciousness, predispose patients to this severe complication. Recently developed preoperative fasting guidelines suggest shorter fasting periods, especially for liquids, providing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing incidence of perioperative pulmonary aspiration. Routine use of drugs decreasing gastric acidity and volume seems to be indicated only for high risk patients. Tracheal intubation after rapid sequence induction of anesthesia is indicated for patients at risk of gastric content aspiration without suspicion of difficult intubation. Adequate indication of the technique, its judicious application and rational use of available drugs may promote excellent intubation conditions, with fast onset, early return to consciousness and spontaneous breathing should tracheal intubation fail. This review intends to discuss methods recently used to control volume and pH of the gastric content, protect the airways during the intubation maneuver and to decrease the gastroesophageal reflux.

Anesthetic management of a patient with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Case report.

BACKGROUND AND OBJECTIVES: Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disorder characterized by mucocutaneous and visceral vascular dysplasia associated with frequent episodes of epistaxis and gastrointestinal bleeding. The objective of this report was to describe the anesthesia of a patient with this syndrome. CASE REPORT: A 25 years old male patient underwent surgical correction of an orbital fracture. He had the triad of recurrent epistaxis, family history and telangiectasia, and had been diagnosed with HHT. Pulmonary, brain, or gastrointestinal tract vascular malformations were not detected in the preoperative investigation. The patient underwent total venous anesthesia one hour after the administration of an antifibrinolytic drug. Bleeding was considered normal for this type of surgery, and hemodynamic instability or the need of perioperative blood transfusion was not detected. The patient was extubated in the operating room; he was transferred to the room after 60 minutes and discharged from the hospital after 24 hours. CONCLUSIONS: Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder that leads to mucocutaneous and visceral vascular dysplasia. Perioperative blood loss can be greater than expected in patients with this syndrome. Since bleeding does not result from a defect in the coagulation cascade but from the surgical exposure of malformed vascular structures, perioperative conduct includes the use of antifibrinolytics, adequate homeostasis, and induced hypotension in the absence of contraindications. Preanesthetic evaluation should include the search for brain, lung, and gastrointestinal vascular malformation.

Manuseio anestésico de paciente portador de telangiectasia hemorrágica hereditária (síndrome de Rendu-Osler-Weber): relato de caso / Manoseo anestésico de paciente portador de telangiectasia hemorrágica hereditaria (síndrome de Rendu - Osler - Weber): relato de caso / Anesthetic management of a patient with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome): case report

JUSTIFICATIVA E OBJETIVOS: A telangiectasia hemorrágica hereditária (THH), também conhecida como síndrome de Rendu-Osler-Weber, é uma doença autossômica dominante, caracterizada por displasia vascular mucocutânea e visceral associada a episódios freqüentes de epistaxe e sangramentos gastrintestinais. O objetivo do presente relato foi descrever a anestesia em paciente portador dessa síndrome. RELATO DO CASO: Paciente do sexo masculino, 25 anos, submetido à correção cirúrgica de fratura de órbita esquerda. Portador da tríade epistaxe recorrente, histórico familiar e telangectasia, apresentava diagnóstico de THH. Durante a investigação pré-operatória não foram encontradas malformações vasculares pulmonares, encefálicas ou do trato gastrintestinal. O paciente foi submetido à anestesia venosa total, uma hora após a administração profilática de antifibrinolítico. O sangramento foi considerado normal para a operação proposta e não houve instabilidade hemodinâmica ou necessidade de transfusão sanguínea perioperatória. A extubação ocorreu na sala cirúrgica e o paciente foi liberado para o quarto após 60 minutos e a alta hospitalar foi após 24 horas. CONCLUSÕES: A THH é uma doença autossômica dominante que provoca displasia vascular musculocutânea e visceral. Pode haver perda sanguínea perioperatória acima da esperada para pacientes portadores dessa síndrome. Como o sangramento não é resultado de defeito na cascata de coagulação mas da exposição cirúrgica da estrutura vascular malformada, a conduta perioperatória inclui o emprego de antifibrinolíticos, a realização de hemostasia adequada e da hipotensão arterial induzida, quando não houver contra-indicação. A avaliação pré-anestésica deve incluir a pesquisa de malformações vasculares encefálicas, pulmonares ou do trato gastrintestinal.

JUSTIFICATIVA Y OBJETIVOS: La telangiectasia hemorrágica hereditaria (THH), también conocida como síndrome de Rendu-Osler-Weber, es una enfermedad autosómica dominante, caracterizada por displasia vascular muco-cutánea y visceral asociada a frecuentes episodios de epistaxis y sangramientos gastrointestinales. El objetivo del presente relato fue el de describir la anestesia en paciente portador de ese síndrome. RELATO DEL CASO: Paciente del sexo masculino, 25 años, sometido a la corrección quirúrgica de fractura de órbita izquierda. Portador de la tríade epistaxis recurrente, historial familiar y telangiectasia presentaba diagnóstico de THH. Durante la investigación preoperatoria no se encontraron malformaciones vasculares pulmonares, encefálicas o del tracto gastrointestinal. El paciente se sometió a la anestesia venosa total, una hora después de la administración profiláctica de antifibrinolítico. El sangramiento fue considerado normal para la operación propuesta, y no hubo inestabilidad hemodinámica o necesidad de transfusión sanguínea perioperatoria. La extubación fue hecha en la sala de cirugía, y el paciente fue enviado a la habitación 60 minutos después. El alta fue en 24 horas. CONCLUSIONES: La THH es una enfermedad autosómica dominante, caracterizada por displasia vascular muco-cutánea y visceral. Puede haber pérdida sanguínea perioperatoria por encima de la esperada para pacientes portadores de ese síndrome. Como el sangramiento no es resultado de un defecto en la cascada de coagulación, sino de la exposición quirúrgica de la estructura vascular malformada, la conducta perioperatoria incluye el uso de antifibrinolíticos, la realización de una hemostasis adecuada y la hipotensión arterial inducida, cuando no haya contraindicación. La evaluación preanestésica debe incluir la investigación de malformaciones vasculares encefálicas, pulmonares o del tracto gastrointestinal.

BACKGROUND AND OBJECTIVES: Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is an autosomal dominant disorder characterized by mucocutaneous and visceral vascular dysplasia associated with frequent episodes of epistaxis and gastrointestinal bleeding. The objective of this report was to describe the anesthesia of a patient with this syndrome. CASE REPORT: A 25 years old male patient underwent surgical correction of an orbital fracture. He had the triad of recurrent epistaxis, family history, and telangiectasia, and had been diagnosed with HHT. Pulmonary, brain, or gastrointestinal tract vascular malformations were not detected in the preoperative investigation. The patient underwent total venous anesthesia one hour after the administration of an antifibrinolytic drug. Bleeding was considered normal for this type of surgery, and hemodynamic instability or the need of perioperative blood transfusion was not detected. The patient was extubated in the operating room; he was transferred to the room after 60 minutes and discharged from the hospital after 24 hours. CONCLUSIONS: Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder that leads to mucocutaneous and visceral vascular dysplasia. Perioperative blood loss can be greater than expected in patients with this syndrome. Since bleeding does not result from a defect in the coagulation cascade but from the surgical exposure of malformed vascular structures, perioperative conduct includes the use of antifibrinolytics, adequate homeostasis, and induced hypotension in the absence of contraindications. Pre-anesthetic evaluation should include the search for brain, lung, and gastrointestinal vascular malformation.

Intubação traqueal e o paciente com o estômago cheio / Tracheal intubation and the patient with a full stomach

A aspiração pulmonar do conteúdo gástrico, apesar de pouco frequente, exige cuidados especiais para sua prevenção. A depressão da consciência durante a anestesia predispõe os pacientes a esta grave complicação pela diminuição na função do esfíncter esofágico e dos reflexos protetores das vias aéreas. Guias de jejum pré-operatório elaborados recentemente sugerem períodos menores de jejum, principalmente para líquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratação, sem aumentar a incidência de aspiração pulmonar perioperatória. O uso rotineiro de agentes que diminuem a acidez e volume gástrico parece estar indicado apenas para pacientes de risco. A intubação traqueal após indução anestésica por meio da técnica de sequência rápida está indicada naqueles pacientes, com risco de aspiração gástrica, em que não há suspeita de intubação traqueal difícil. A indicação correta da técnica, sua aplicação criteriosa e a utilização racional das drogas disponíveis podem promover condições excelentes de intubação, com curto período de latência, rápido retorno da consciência e da respiração espontânea, caso haja falha na intubação traqueal.O presente artigo tem como objetivo discutir os métodos atualmente utilizados para controlar o volume e o pH do conteúdo gástrico, proteger as vias aéreas durante as manobras de intubação e reduzir o refluxo gastroesofágico.

Pulmonary aspiration of gastric contents, despite its infrequent occurrence, demands special preventive care. Decreased oesophageal sphincter function and protective airway reflexes caused by depression of consciousness, predispose patients to this severe complication. Recently developed preoperative fasting guidelines suggest shorter fasting periods, especially for liquids, providing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing incidence of perioperative pulmonary aspiration. Routine use of drugs decreasing gastric acidity and volume seems to be indicated only for high risk patients. Tracheal intubation after rapid sequence induction of anesthesia is indicated for patients at risk of gastric content aspiration without suspicion of difficult intubation. Adequate indication of the technique, its judicious application and rational use of available drugs may promote excellent intubation conditions, with fast onset, early return to consciousness and spontaneous breathing should tracheal intubation fail. This review intends to discuss methods recently used to control volume and pH of the gastric content, protect the airways during the intubation maneuver and to decrease the gastroesophageal reflux.

Compression of the cricoid cartilage. Current aspects.

BACKGROUND AND OBJECTIVES: Sellick described the importance of applying pressure in the cricoid cartilage during anesthesia induction to prevent regurgitation of gastric contents. Since then, the maneuver has been widely accepted by anesthesiologists as a fundamental step during induction with the rapid sequence technique. The objective of the present report was to discuss the indications, technique, complications, and reasons why some authors have refuted the efficacy of this technique. CONTENTS: The indications, technique, and complications of compression of the cricoid cartilage were reviewed. The aspects that have motivated some authors to abandon the Sellick maneuver during anesthetic induction with the rapid sequence technique are also discussed. CONCLUSIONS: The cricoid cartilage pressure maneuver requires knowledge of the anatomy of upper airways and the correct force to be used. Endoscopic and radiologic studies, as well as patients who developed pulmonary aspiration despite the use of Sellick maneuver, have raised doubts about the usefulness of this technique. Besides, can cause deformity of the cricoid cartilage, closure of the vocal cords, and difficulty to ventilate if it is not used properly. Despite the importance given to Sellick maneuver in preventing pulmonary aspiration, there are no guarantees it will protect the airways of all patients, especially when the technique is not properly used.