RESUMO
BACKGROUND AND OBJECTIVES: Several resources can be used for the approach of the airways. Maintaining a patient awake when control of ventilation/oxygenation is uncertain is an option when intubation is doubtful. Blind nasotracheal intubation (NTI) is an alternative to fiberoptic endoscopy. CASE REPORT: A 75-year old patient, weighing 56 kg, was scheduled for hemimandibulectomy; she presented cervical immobility secondary to arthrodesis, mouth opening of 2.2 cm, moderate retrognatism, voluntary protrusion of the mandible was absent, mentostemal distance of 11 cm and mento-thyroid distance of 6 cm, therefore receiving a score of 5 on the Wilson scale. The patient signed an informed consent after being informed about the procedure. After monitoring and oxygenation, continuous infusion of dexmedetomidine was initiated. Superior and inferior laryngeal nerve block was performed with 2.0% lidocaine without vasoconstrictor and the hypopharinx was anesthetized with a lidocaine spray. Before NTI, ondansetron, midazolam, fentanyl, and droperidol were administered and the patient remained awake and cooperative. Nasal insertion of the tracheal tube was oriented by its opacification and respiratory sounds and the placement was confirmed by pulmonary auscultation and capnography. Continuous infusion of propofol and remifentanil was instituted, vecuronium was administered and controlled ventilation was initiated. The surgery lasted 60 minutes without intercurrences. At the end, the patient was breathing spontaneously, so she was extubated and transferred to the recovery room from where she was discharged without any complaints. CONCLUSION: Nasotracheal intubation is an alternative to fiberoptic endoscopy when safety and control of the airways is uncertain. Informing the patient about the procedure was essential. Safety was assured and respiratory depression and hemodynamic instability was not observed.
Assuntos
Intubação Intratraqueal/métodos , Mandíbula/cirurgia , Idoso , Feminino , HumanosRESUMO
BACKGROUND AND OBJECTIVES: There are reports on epidural blood patch in Jehovah's Witness patients using a closed system which allows blood collection and epidural injection without loss of continuity. This report aimed at presenting two cases of Jehovah's Witness patients with post-dural puncture headache and treated with epidural blood patch in a closed venous blood transfusion system to the epidural space. Cases were reported by two different hospitals in two different cities. CASE REPORTS: One 21 years old male patient and one 32 years old female patient, with post-dural puncture headache after outpatient procedures. Since they were Jehovah's Witnesses, blood patch was performed with a closed system. System was prepared in sterile conditions using the following materials: two serum catheters cut in 60 cm segments, one two-way connection, one three-way tap and one 20 ml syringe. System was assembled to allow one connection to the puncture needle (20G), one connection to the three-way tap and the remaining two ways were connected to a 20 ml syringe and to the other serum catheter segment, which would be connected to the epidural needle. Lumbar region and right upper limb were disinfected with patients in the left lateral position. Epidural puncture was performed at L2-L3 interspace with 17G needle which was maintained fixed and connected to the serum catheter. Then, venous puncture was performed with a needle connected to the other edge of the serum catheter with the three-way tap directed from the vein to the syringe and 15 ml blood were aspirated. Redirecting the tap from the syringe to the epidural needle, the same 15 ml blood were re-injected. CONCLUSIONS: In Jehovah's Witness patients refractory to clinical treatment, autologous blood injection may be performed through the above-described technique after patients informed consent.
RESUMO
BACKGROUND AND OBJECTIVES: Epidural opioids, associated or not to local anesthetics, have been used for postoperative analgesia in continuous infusion and/or patient controlled boluses. The aim of this study was to compare postoperative analgesia provided by epidural fentanyl or sufentanil, in bolus or continuous infusion, in patients submitted to knee ligament reconstruction. METHODS: Seventy ASA I - II patients, aged 16 to 47 years, were randomly distributed in two groups. All patients were submitted to epidural anesthesia with 0.5% bupivacaine (100 mg) with epinephrine 1:200,000 associated to fentanyl (100 mg). At the end of the procedure, patients received epidural fentanyl (Group F) or sufentanil (Group S) in continuous infusion plus patient controlled boluses. Group F infusion solution was made of saline (85 ml), 500 microg fentanyl (10 ml) and 0.5% bupivacaine (5 ml). Group S solution was made of saline (92 ml), 150 microg sufentanil (3 ml) and 0.5% plain bupivacaine (5 ml). Infusion pump's flow was initially programmed to 5 ml h(-1), with 2 ml patient controlled bolus doses every 15 minutes at most, for both groups. The following parameters were compared: pain, number of patient controlled boluses, opioid consumption, motor block, sedation and side-effects. RESULTS: There have been no statistically significant difference in analgesia quality between groups, being in most cases rated good (AVS 0 to 2). There has been a significant difference in the number of patient controlled boluses, with Group F needing more boluses than Group S. There has been no difference in total infused solution volume and total infusion time. There has been no motor block after beginning of patient-controlled analgesia. Vomiting and urine retention incidences were higher in Group S and there have been no significant differences in sedation and pruritus between groups. CONCLUSIONS: Epidural fentanyl or sufentanil in continuous epidural infusion and patient-controlled boluses in the doses used in this study have induced excellent postoperative analgesia. However, sufentanil caused more severe side effects than fentanyl.
