Case report - Gluteal hematoma in two spinal cord patients on enoxaparin for venous thromboembolism prophylaxis: evidence needed for a wiser choice.

Introduction: Acute spinal cord injury is associated with an increased risk of thromboembolic events. Low-molecular-weight heparins are first-line medications for both the treatment and prevention of venous thromboembolism. Pharmacological prophylaxis may be indicated for high-risk patients and low-risk patients may be managed with non-pharmacological measures. Case presentation: We report two cases of gluteal hematomas that occurred in patients with chronic spinal cord injury who were under prophylactic doses of enoxaparin at a tertiary rehabilitation hospital. There was no local trauma. The patients needed multiple surgical interventions and rehabilitation treatment was delayed. Discussion: There is a lack of evidence to correctly estimate the thromboembolic risk in chronic spinal cord injury and the duration of prophylaxis. Over-prescription of pharmacological prophylaxis may expose patients to unnecessary risks. These patients frequently present with polypharmacy and reducing the amount of prescribed medication may begin with reducing prophylactic treatments for venous thromboembolism, which may be an overtreatment based on risk overestimation.

Comparison of two pharmacological prophylaxis strategies for venous thromboembolism in spinal cord injury patients: a retrospective study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the cost and incidence of venous thromboembolism (VTE) and bleeding between two different VTE pharmacological prophylaxis strategies in individuals with spinal cord injury: one based on motor impairment (Protocol 1) and the other based on time from the lesion and presence of associated risk factors for VTE (Protocol 2). SETTING: A tertiary rehabilitation hospital in Brazil. METHODS: We retrospectively reviewed a total of 1475 charts of individual admissions: 814 individuals received pharmacological prophylaxis according to Protocol 1 and 661 according to protocol 2. These cohorts were compared with respect to age, time and level of injury, length of stay, AIS classification, type of injury, and occurrence of VTE and major bleeding. The number of prescribed doses of enoxaparin and expenditures associated with enoxaparin during each period were evaluated. RESULTS: The median lesion time was 3 years. The risk-based strategy drastically reduced the average monthly use of enoxaparin by 75% and the 12-month enoxaparin expenditure by $119,930.33, without increasing the risk of VTE. The incidence density of thromboembolic events was 0.55/10,000 patient-days, and all events occurred in individuals receiving prophylaxis according to Protocol 1. CONCLUSIONS: Time from injury and risk of VTE-based protocol for indication of pharmacological prophylaxis drastically reduced costs. No difference in occurrence of VTE was observed.

Antibiotic prophylaxis prior to urodynamic study in patients with traumatic spinal cord injury. Is there an indication?

ABSTRACT Study design: Retrospective cohort of patients with traumatic spinal cord injury (SCI) that have been hospitalized for physical-functional rehabilitation purposes. Objectives: To compare the incidence of urinary tract infection (UTI) after urodynamic study (UDS) in three hospitals that adopted different protocols with regard to the preparation of patients. Setting: Sarah Network of Rehabilitation Hospitals, Brazil. Materials and Methods: Between 2014 and 2015, 661 patients from three units of the same hospital network, one of which does not use antimicrobial prophylaxis independently of urine culture results, were evaluated after having undergone UDS. The results were compared in both univariate and multivariate analyses (logistic regression). Results: The global rate of UTI after UDS was that of 3.18% (IC 95% 2.1-4.8), with no differences between the units. In the univariate analysis the only variable that was associated with UTI after UDS was that of T6 injuries or above (P = 0.029). The logistic regression has confirmed this result, with an adjusted odds ratio of 3.06 (IC 95% 1.01 to 9.26; P = 0.0476). The use of antimicrobial prophylaxis did not alter that risk. Conclusions: This study has demonstrated that the use of antimicrobials does not prevent UTI after UDS. Patients with T6 traumatic SCI or above have got three times more chance of developing UTI after UDS if compared to those with a T7 injury or below, independently of the use of antimicrobials. Even in these patients the use of antimicrobials would not be justified.

Brachial Plexus Injuries with Ulnar Musculocutaneous Transfer: 78 Cases Study Focused on Possible Postoperative Complications

Objective To analyze 78 cases of brachial plexus injury submitted to the Oberlin technique between 2003 and 2012. The potential complications of this technique were analyzed, especially motor damage or hypoesthesia of the hand. Method Medical records from patients with brachial plexus injuries at the levels of the C5-C6 and C5-C6-C7 vertebrae were retrospectively analyzed. Cases submitted to the Oberlin procedure with or without concomitant brachial plexus procedures between 2003 and 2012 were evaluated. The minimum follow-up period was of 1 year. In addition to the clinical examination, electromyography and magnetic resonance imaging (MRI) of the brachial plexus were used to diagnose and locate the nerve damage. Results A total of 78 surgical patients met the inclusion criteria. Postoperative neurological changes, mostly transient, were observed in 18 patients. Hypoesthesia in the ulnar side of the handwas observed in seven cases; neuropathic pain in five cases; allodynia in four cases, and hand motor loss in two cases. Conclusion Based on the results of the present case series, we conclude that there are few sequelae in the donor nerve territory compared with the benefit of the Oberlin technique on the recovery of elbow flexion after brachial plexus injuries.

Antibiotic prophylaxis prior to urodynamic study in patients with traumatic spinal cord injury. Is there an indication?

STUDY DESIGN: Retrospective cohort of patients with traumatic spinal cord injury (SCI) that have been hospitalized for physical-functional rehabilitation purposes. OBJECTIVES: To compare the incidence of urinary tract infection (UTI) after urodynamic study (UDS) in three hospitals that adopted different protocols with regard to the preparation of patients. SETTING: Sarah Network of Rehabilitation Hospitals, Brazil. MATERIALS AND METHODS: Between 2014 and 2015, 661 patients from three units of the same hospital network, one of which does not use antimicrobial prophylaxis independently of urine culture results, were evaluated after having undergone UDS. The results were compared in both univariate and multivariate analyses (logistic regression). RESULTS: The global rate of UTI after UDS was that of 3.18% (IC 95% 2.1-4.8), with no differences between the units. In the univariate analysis the only variable that was associated with UTI after UDS was that of T6 injuries or above (P = 0.029). The logistic regression has confi rmed this result, with an adjusted odds ratio of 3.06 (IC 95% 1.01 to 9.26; P = 0.0476). The use of antimicrobial prophylaxis did not alter that risk. CONCLUSIONS: This study has demonstrated that the use of antimicrobials does not prevent UTI after UDS. Patients with T6 traumatic SCI or above have got three times more chance of developing UTI after UDS if compared to those with a T7 injury or below, independently of the use of antimicrobials. Even in these patients the use of antimicrobials would not be justified.

Factors Associated With Intestinal Constipation in Chronic Patients With Stroke Sequelae Undergoing Rehabilitation.

The objective of this study was to define which stroke-related factors constitute independent variables in the incidence of intestinal constipation (IC) of chronic patients admitted to a hospital rehabilitation program. All patients consecutively admitted for rehabilitation were recruited for the study. In the Poisson multiple regression analysis using a hierarchical model, sociodemographic variables, comorbidities, medication, previous history of constipation, life habits, and stroke-related variables were considered for defining factors associated with IC. A 31% prevalence (95% confidence interval [CI]: 25.3-37.1) of IC was detected. Among the factors associated, female gender (adjusted prevalence ratio [PRadjusted] = 1.79; 95% CI: 1.20-2.68), intestinal complaints prior to stroke (PRadjusted = 3.71; 95% CI: 2.60-5.31), intake of less than 800 ml of fluid per day (PRadjusted = 1.72; 95% CI: 1.20- 2.45), age greater than 65 years at brain injury (PRadjusted = 1.67; 95% CI: 1.01-2.75), and partially impaired anterior brain circulation (PRadjusted = 3.35; 95% CI: 1.02-10.97) were associated with IC. Female gender, elderly, prior history of IC, low fluid intake, and partial impairment of anterior brain circulation were factors independently associated with IC in stroke survivors undergoing rehabilitation. These findings require further validation and may serve toward improving bowel retraining programs for this patient group.

Fatores de risco de complicações pulmonares em pacientes com sarcoma após toracotomia para a ressecção de nódulos pulmonares / Risk factors for pulmonary complications in patients with sarcoma after the resection of pulmonary nodules by thoracotomy

OBJETIVO: Identificar os fatores de risco para complicações pulmonares em pacientes com sarcoma após serem submetidos a toracotomia para a ressecção de nódulos pulmonares. MÉTODOS: Estudo de coorte retrospectivo com 68 pacientes consecutivos com diagnóstico de sarcomas e submetidos a 174 toracotomias para a ressecção de nódulos pulmonares. A variável dependente foi definida como a ocorrência de qualquer complicação pulmonar pós-operatória. As variáveis independentes foram relacionadas com o paciente, o diagnóstico de base e o tipo de procedimento cirúrgico. Os dados foram analisados segundo um modelo multivariado de estimação de equações generalizadas, com uma função de ligação logística e uma estrutura de correlação simétrica. RESULTADOS: Houve 24 complicações (13,8 por cento; IC95 por cento: 9,0-19,8), incluindo um óbito. Os pacientes que apresentaram complicações pós-operatórias tiveram um tempo médio de internação duas vezes superior àqueles sem complicações (18,8 ± 10,0 dias vs. 8,6 ± 6,0 dias; p < 0,05). As variáveis que se correlacionaram com o desfecho foram o tipo de ressecção (em cunha ou anatômica; OR = 3,6; IC95 por cento: 1,5-8,8), necessidade de transfusão sanguínea (OR = 9,8; IC95 por cento: 1,6-60,1) e número de nódulos ressecados (OR = 1,1; IC95 por cento: 1,0-1,1). O modelo multivariado obtido exibiu uma área sob a curva ROC de 0,75 (IC95 por cento: 0,65-0,85). CONCLUSÕES: As complicações pulmonares pós-operatórias após a ressecção de nódulos pulmonares em pacientes com sarcoma não foram raras, ocorrendo em cerca de 10 por cento dos procedimentos. A ocorrência dessas complicações pode ser antecipada pelo uso de ressecção não em cunha, necessidade de hemotransfusão e maior número de nódulos ressecados. Assim, já no pós-operatório imediato, é possível identificar pacientes de risco, que devem ser estritamente monitorizados durante o período pós-operatório imediato. Para esses pacientes, todas as medidas preventivas devem ser tomadas.

OBJECTIVE: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. METHODS: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. RESULTS: Complications were observed in 24 patients (13.8 percent, 95 percent CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95 percent CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95 percent CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95 percent CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95 percent CI: 0.65-0.85). CONCLUSIONS: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10 percent of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

Risk factors for pulmonary complications in patients with sarcoma after the resection of pulmonary nodules by thoracotomy.

OBJECTIVE: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. METHODS: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. RESULTS: Complications were observed in 24 patients (13.8%, 95% CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95% CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95% CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95% CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95% CI: 0.65-0.85). CONCLUSIONS: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10% of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

Epidural lumbar block or lumbar plexus block combined with general anesthesia: efficacy and hemodynamic effects on total hip arthroplasty.

BACKGROUND AND OBJECTIVES: Anesthesia for total hip arthroplasty (THA) is a challenge due to the advanced age and associated diseases of patients. The objective of this study was to evaluate whether the efficacy of the nociceptive blockade, secondary hemodynamic effects, difficulty to execute the technique, and influence in intraoperative bleeding of lumbar plexus block combined with general anesthesia is equivalent to epidural lumbar block in patients undergoing THA. METHODS: Patients with physical status ASA I to III were randomly separated into two groups, Epidural and Lumbar. In the Epidural group, continuous epidural lumbar block with 10 to 15 mL of 0.5% ropivacaine was performed. Patients in the Lumbar group underwent posterior lumbar plexus block with 0.4 mL.kg(-1) of 0.5% ropivacaine. All patients underwent general anesthesia. The difficulty to perform the technique, its efficacy, and secondary hemodynamic effects were evaluated. RESULTS: Forty-one patients were included in this study. The length of time to execute the epidural block was shorter, but the number of attempts to position the needle was similar in both groups. Epidural block was more effective. In the Lumbar group, an increase in diastolic blood pressure and mean arterial pressure (MAP) and in the double product was observed after the incision, and anesthetic consumption was greater. After the blockade, MAP was lower 50, 60, and 70 minutes after the epidural block. Bleeding was similar in both groups. CONCLUSIONS: Nociceptive blockade, which was not associated with hemodynamic instability when combined with general anesthesia, was more effective in epidural block. Lumbar plexus block proved to be a useful technique when combined with general anesthesia when epidural block is contraindicated.

Influence of angiotensin-converting enzyme inhibitors on hypotension after anesthetic induction: is the preoperative discontinuation of this drug necessary?

BACKGROUND AND OBJECTIVES: The discontinuation of drugs such as angiotensin-converting enzyme inhibitors (ACE inhibitors) has been suggested based on reports of hypotension during anesthesia. This may imply on a higher risk of intraoperative hypertensive peaks with deleterious consequences for the patient. The objective of the present study was to evaluate the influence of the preoperative use of ACE inhibitors on the development of hypotension during anesthesia. METHODS: This is a case-controlled study of patients who developed hypotension after anesthetic induction. The control group was composed of patients of the same age and gender who underwent surgeries during the same period and who did not develop hypotension. Parameters of interest included: age, gender, size of the surgery, prior diagnosis of hypertension, use of ACE inhibitors, physical status (ASA), intraoperative bleeding, anesthetic technique, and duration of the surgery. RESULTS: In 2,179 surgeries, 40 patients developed hypotension. Twenty of those patients used ACEIs on the day of the surgery. The control group was composed by 171 patients, 11 of which used ACE inhibitors. Univariate analysis showed an association between hypertension and advanced age (p < 0.001), prior diagnosis of hypertension (p < 0.001), use of ACEIs (p = 0.006), physical status (ASA) (p = 0.006), and size of the surgery (p = 0.028). Stratified analysis did not show an association between hypotension and use of ACE inhibitors. On logistic regression, the association between the size of the surgery and the age of the patient and the development of hypotension remained. CONCLUSIONS: We did not observe an association between the use of ACE inhibitors and hypotension during anesthesia. The authors considered that the recommendation to discontinue ACE inhibitors on the day before the surgery should be reviewed. Other studies are necessary to confirm those results.

Anestesia peridural lombar ou bloqueio do plexo lombar combinados à anestesia geral: eficácia e efeitos hemodinâmicos na artroplastia total do quadril / Epidural lumbar block or lumbar plexus block combined with general anesthesia: efficacy and hemodynamic effects on total hip arthroplasty / Anestesia epidural lumbar o bloqueo del plexo lumbar combinados con la anestesia general: eficacia y efectos hemodinámicos en la artroplastia total de lacadera

Justificativa e objetivos: A anestesia para artroplastia total do quadril (ATQ) constitui desafio devido à idade avançada e às doenças associadas dos pacientes. O objetivo do estudo foi avaliar se o bloqueio do plexo lombar combinado à anestesia geral se equivale à anestesia peridural lombar quanto à eficácia do bloqueio nociceptivo, efeitos hemodinâmicos secundários, dificuldade na sua execução e influência no sangramento operatório...

Background and objectives: Anesthesia for total hip arthroplasty (THA) is a challenge due to the advanced age and associated diseases of patients. The objective of this study was to evaluate whether the efficacy of the nociceptive blockade, secondary hemodynamic effects, difficulty to execute the technique, and influence in intraoperative bleeding of lumbar plexus block combined with general anesthesia is equivalent to epidural lumbar...

Justificativa y objetivos: La anestesia para la artroplastia total de la cadera (ATC), constituye un reto a causa de la edad avanzada y de las enfermedades asociadas a los pacientes. El objetivo del estudio, fue evaluar si el bloqueo del plexo lumbar combinado con la anestesia general, equivale a la anestesia epidural lumbar en cuanto a la eficacia del bloqueo nociceptivo, efectos hemodinámicos secundarios, dificultad en su ejecución e influencia en el sangramiento operatorio...

Influência do uso crônico dos inibidores da enzima conversora da angiotensina na hipotensão arterial após indução anestésica: é necessário suspender esse fármaco no pré-operatório? / Influencia del uso crónico de los inhibidores de la enzima conversora de la angiotensina en la hipotensión arterial después de la inducción anestésica: ¿es necesario suspender ese fármaco en el preoperatorio? / Influence of angiotensin-converting enzyme inhibitors on hypotension after anesthetic induction: is the preoperative discontinuation of this drug necessary?

Justificativa e objetivos: Tem sido sugerida a suspensão de medicamentos como os inibidores da enzima conversora de angiotensina (IECA) com base em relatos de hipotensão arterial durante a anestesia. Isso pode implicar em maior risco de picos hipertensivos no intraoperatório, com efeitos deletérios para o paciente. O objetivo deste estudo foi avaliar a influência dos IECA utilizados no pré-operatório na ocorrência de hipotensão arterial...

Background and objetives: The discontinuation of drugs such as angiotensin-converting enzyme inhibitors (ACE inhibitors) has been suggested based on reports of hypotension during anesthesia. This may imply on a higher risk of intraoperative hypertensive peaks with deleterious consequences for the patient. The objective of the present study was to evaluate the influence of the preoperative use of ACE inhibitors on the development of hypotension...

Justificativa y objetivos: En base a relatos de hipotensión arterial durante la anestesia, se ha sugerido la suspensión de medicamentos como los inhibidores de la enzima conversora de angiotensina (IECA). Eso puede redundar en un riesgo más elevado de picos hipertensivos en el intraoperatorio y con efectos perjudiciales para el paciente. El objetivo de este estudio, fue evaluar la influencia de los IECA utilizados en el preoperatorio si surge la hipotensión arterial...

Efeitos da analgesia peridural e do bloqueio contínuo do plexo lombar sobre a reabilitação funcional após artroplastia total do quadril / Efectos de la analgesia epidural y del bloqueo continuo del plexo lumbar sobre la rehabilitación funcional después de la artroplastia total de cadera / Effects of epidural analgesia and continuous lumbar plexus block on functional rehabilitation after total hip arthroplasty

JUSTIFICATIVA E OBJETIVOS: A dor após artroplastia total do quadril (ATQ) é intensa e agravada pelas mobilizações, o que demanda técnica analgésica eficaz e que permita mobilidade precoce, participação nas atividades de reabilitação e rápida recuperação funcional. O objetivo do estudo foi comparar os efeitos das técnicas de analgesia controlada pelo paciente (ACP) pelas vias peridural e perineural do plexo lombar sobre a reabilitação funcional em pacientes submetidos à ATQ. MÉTODO: Pacientes estado físico ASA I a III foram alocados aleatoriamente nos grupos Peridural e Lombar. Para a ATQ, foi realizada anestesia peridural lombar contínua com ropivacaína a 0,5 por cento (Peridural) ou bloqueio contínuo do plexo lombar com ropivacaína a 0,5 por cento (Lombar). Na sala de recuperação, iniciou-se ACP com infusão de ropivacaína a 0,2 por cento (Lombar) ou ropivacaína a 0,2 por cento + fentanil 3 µg.mL-1 (Peridural). A eficácia da analgesia nas primeiras 48 horas após a ATQ (escores de dor, consumo de morfina de resgate e de bolos da bomba de ACP) foi comparada entre os grupos. Diferentes parâmetros da reabilitação pós-operatória foram estudados. RESULTADOS: Quarenta e um pacientes foram submetidos à análise estatística. Os escores de dor em repouso foram semelhantes nos dois grupos. Apesar do controle mais efetivo da dor dinâmica no grupo Peridural e o uso de morfina ter sido maior, mais frequente e mais precoce no grupo Lombar, não houve diferença entre os grupos em nenhum dos parâmetros estudados de reabilitação. As técnicas de analgesia não influenciaram as falhas no processo de reabilitação. CONCLUSÕES: A maior efetividade da analgesia peridural não se traduziu em melhora no processo de reabilitação, nem reduziu o tempo necessário para alcançar os desfechos estudados.

BAKGROUND AND OBJECTIVES: Pain after total hip arthroplasty (THA) is severe and it is aggravated by movements, which requires an effective analgesic technique that allows early mobilization, participation in rehabilitation activities, and fast functional recovery. The objective of this study was to compare the effects of epidural and perineural patient-controlled analgesia (PCA) of the lumbar plexus on functional rehabilitation of patients undergoing THA. METHODS: Patients classified as physical status ASA I to III were randomly divided into two groups: Epidural and Lumbar. For THA, patients underwent continuous epidural lumbar block with 0.5 percent ropivacaine (Epidural) or continuous lumbar plexus block with 0.5 percent ropivacaine (Lumbar). In the recovery room, PCA with infusion of 0.2 percent ropivacaine (Lumbar) or 0.2 percent ropivacaine + fentanyl 3 µg.mL-1 (Epidural) was instituted. Analgesic efficacy in the first 48 hours after THA (pain scores, rescue morphine consumption, and bolus of the PCA pump) was compared between both groups. Different postoperative rehabilitation parameters were analyzed. RESULTS: Forty-one patients underwent statistical analysis. Resting pain scores were similar in both groups. Despite more effective control of dynamic pain in the Epidural group and the greater, more frequent, and earlier morphine consumption in the Lumbar group, rehabilitation parameters evaluated did not differ in both groups. Analgesia techniques did not affect rehabilitation failures. CONCLUSIONS: The greater effectivity of epidural analgesia did not translate in improvement of the rehabilitation process nor did it decrease the time necessary to achieve end goals.

JUSTIFICATIVA Y OBJETIVOS: El dolor después de la artroplastia total de la cadera (ATC) es intenso y se agrava por los movimientos, lo que demanda una técnica analgésica eficaz y que permita la movilidad precoz, la participación en las actividades de rehabilitación, y una rápida recuperación funcional. El objetivo de este estudio, fue comparar los efectos de las técnicas de analgesia controlada por el paciente (ACP), por las vías epidural y perineural del plexo lumbar sobre la rehabilitación funcional en pacientes sometidos a la ATC. MÉTODO: Pacientes en estado físico ASA I a III, que fueron ubicados aleatoriamente en los grupos Epidural y Lumbar. Para la ATC, se realizó la anestesia epidural lumbar continua con ropivacaína a 0,5 por ciento (Epidural) o bloqueo continuo del plexo lumbar con ropivacaína a 0,5 por ciento (Lumbar). En la sala de recuperación, se inició ACP con infusión de ropivacaína a 0,2 por ciento (Lumbar) o ropivacaína a 0,2 por ciento + fentanil 3 µg.mL-1 (Epidural). La eficacia de la analgesia en las primeras 48 horas después de la ATC (niveles de dolor, consumo de morfina de rescate y de bolos de la bomba de ACP), se comparó entre los grupos. Los diferentes parámetros de la rehabilitación postoperatoria también se estudiaron. RESULTADOS: Cuarenta y un pacientes se sometieron al análisis estadístico. Los niveles de dolor en reposo fueron similares en los dos grupos. A pesar de un control más efectivo del dolor dinámico en el grupo Epidural y de un uso más potente de la morfina, que se aplicó más a menudo y precozmente en el grupo Lumbar, no hubo diferencia entre los grupos en ninguno de los parámetros estudiados de rehabilitación. Las técnicas de analgesia no influyeron en las fallas en el proceso de rehabilitación. CONCLUSIONES: El más alto nivel de efectividad de la analgesia epidural, no se tradujo en una mejoría en el proceso de rehabilitación, ni tampoco redujo el tiempo necesario para alcanzar los resultados estudiados.

[Effects of epidural analgesia and continuous lumbar plexus block on functional rehabilitation after total hip arthroplasty]. / Efeitos da analgesia peridural e do bloqueio contínuo do plexo lombar sobre a reabilitação funcional após artroplastia total do quadril.

UNLABELLED: BAKGROUND AND OBJECTIVES: Pain after total hip arthroplasty (THA) is severe and it is aggravated by movements, which requires an effective analgesic technique that allows early mobilization, participation in rehabilitation activities, and fast functional recovery. The objective of this study was to compare the effects of epidural and perineural patient-controlled analgesia (PCA) of the lumbar plexus on functional rehabilitation of patients undergoing THA. METHODS: Patients classified as physical status ASA I to III were randomly divided into two groups: Epidural and Lumbar. For THA, patients underwent continuous epidural lumbar block with 0.5% ropivacaine (Epidural) or continuous lumbar plexus block with 0.5% ropivacaine (Lumbar). In the recovery room, PCA with infusion of 0.2% ropivacaine (Lumbar) or 0.2% ropivacaine + fentanyl 3 microg.mL-1 (Epidural) was instituted. Analgesic efficacy in the first 48 hours after THA (pain scores, rescue morphine consumption, and bolus of the PCA pump) was compared between both groups. Different postoperative rehabilitation parameters were analyzed. RESULTS: Forty-one patients underwent statistical analysis. Resting pain scores were similar in both groups. Despite more effective control of dynamic pain in the Epidural group and the greater, more frequent, and earlier morphine consumption in the Lumbar group, rehabilitation parameters evaluated did not differ in both groups. Analgesia techniques did not affect rehabilitation failures. CONCLUSIONS: The greater effectivity of epidural analgesia did not translate in improvement of the rehabilitation process nor did it decrease the time necessary to achieve end goals.

Noninvasive determination of inspiratory pressure in patients with spinal cord injury: what is the best method?

The aim of the study was to evaluate the performance of sniff nasal inspiratory pressure (SNIP) and MIP in individuals with spinal cord injury. We evaluated 26 patients with spinal cord injury. Mean FVC in those with tetraplegia was 52 +/- 19% of predicted, compared with 78 +/- 23% of predicted in those with paraplegia (p < 0.05). In contrast, the percentage of predicted SNIP was lower in those with tetraplegia than in those with paraplegia (p < 0.05). In all participants, SNIP correlated significantly with the level of the injury (r = 0.489; 95% CI: 0.125-0.737). The impact that the greater discriminatory power of SNIP has on the diagnosis of impaired pulmonary function in spinal cord-injured patients should be investigated further.

Noninvasive determination of inspiratory pressure in patients with spinal cord injury: what is the best method? / Determinação não-invasiva da pressão inspiratória em pacientes com lesão medular traumática: qual é o melhor método?

The aim of the study was to evaluate the performance of sniff nasal inspiratory pressure (SNIP) and MIP in individuals with spinal cord injury. We evaluated 26 patients with spinal cord injury. Mean FVC in those with tetraplegia was 52 ± 19 percent of predicted, compared with 78 ± 23 percent of predicted in those with paraplegia (p < 0.05). In contrast, the percentage of predicted SNIP was lower in those with tetraplegia than in those with paraplegia (p < 0.05). In all participants, SNIP correlated significantly with the level of the injury (r = 0.489; 95 percent CI: 0.125-0.737). The impact that the greater discriminatory power of SNIP has on the diagnosis of impaired pulmonary function in spinal cord-injured patients should be investigated further.

O objetivo deste estudo foi verificar o desempenho da pressão inspiratória nasal durante o fungar (PInas) e da PImáx em indivíduos com lesão medular traumática. Foram avaliados 26 pacientes com lesão medular traumática. Os pacientes tetraplégicos e paraplégicos exibiram diferentes médias do percentual do previsto da CVF, respectivamente, 52 ± 19 por cento e 78 ± 23 por cento (p < 0,05). Ao contrário da PImáx, o percentual do previsto médio da PInas foi inferior nos tetraplégicos (p < 0,05) e, em todos os participantes, a correlação com o nível da lesão foi significativa (r = 0,489; IC95 por cento: 0,125-0,737). O impacto do melhor discernimento da PInas no diagnóstico das alterações da função inspiratória de pacientes com lesão medular traumática merece ser aprofundado.

Patent foramen ovale and ischemic stroke in young people: statistical association or causal relation?

OBJECTIVES: To determine if there are evidences of a causal relation between patent foramen ovale (PFO) x cryptogenic ischemic stroke (IS) in the young population and to analyze this relation in terms of causal criteria. METHODS: A total of 168 young patients with IS was retrospectively evaluated and divided into two groups: cryptogenic and with a defined cause. As a routine procedure, the patients underwent investigation of the PFO by means of transesophageal echocardiogram and/or transcranial Doppler sonography, both of them associated with the bubble test. Multivariate analysis was performed after demonstration of univariate statistical association between PFO x IS. RESULTS: After multivariate analysis, the association between PFO x cryptogenic IS was still statistically significant with odds ratio (adjusted OR = 3.3; 95% CI: 1.5-7.4). The total number of cerebral lesions also presented a significant association with cryptogenic IS (adjusted OR = 0.4; 95% CI: 0.2-0.9). The association between PFO and cryptogenic IS met all the causality criteria. CONCLUSION: The causal relation between PFO and cryptogenic IS in the young population is highly probable. This fact should be considered in the therapeutic decision.

Forame oval patente e acidente vascular cerebral isquêmico em jovens: associação causal ou estatística? / Patent foramen ovale and ischemic stroke in young people: statistical association or causal relation?

OBJETIVOS: Determinar se há evidências de uma relação causal entre forame oval patente (FOP) e acidente vascular cerebral isquêmico (AVCI) criptogênico em jovens. Analisar essa relação à luz dos critérios de causalidade. MÉTODOS: Avaliaram-se, retrospectivamente, 168 pacientes jovens com AVCI, divididos em dois grupos: criptogênico e de causa definida. Como parte da rotina, os pacientes foram submetidos a pesquisa de FOP por ecocardiograma transesofágico e/ou Doppler transcraniano, ambos associados ao teste de bolhas. Demonstrada a associação estatística univariada entre FOP e AVCI, procedeu-se a análise multivariada. RESULTADOS: Após análise multivariada, a associação FOP e AVCI criptogênico mostrou-se ainda estatisticamente significante, com razão de chance (RCajustada de 3,3 (IC95 por cento 1,5-7,4). O número total de lesões no encéfalo também apresentou associação significativa com o AVCI criptogênico (RCajustada= 0,4 IC95 por cento 0,2-0,9). A associação FOP e AVCI criptogênico satisfez todos os critérios de causalidade. CONCLUSÃO: A relação causal entre o FOP e o AVCI criptogênico em jovens é altamente provável. Esse fato deve ser considerado na decisão terapêutica.

OBJECTIVES: To determine if there are evidences of a causal relation between patent foramen ovale (PFO) x cryptogenic ischemic stroke (IS) in the young population and to analyze this relation in terms of causal criteria. METHODS: A total of 168 young patients with IS was retrospectively evaluated and divided into two groups: cryptogenic and with a defined cause. As a routine procedure, the patients underwent investigation of the PFO by means of transesophageal echocardiogram and/or transcranial Doppler sonography, both of them associated with the bubble test. Multivariate analysis was performed after demonstration of univariate statistical association between PFO x IS. RESULTS: After multivariate analysis, the association between PFO x cryptogenic IS was still statistically significant with odds ratio (adjusted OR = 3.3; 95 percent CI: 1.5-7.4). The total number of cerebral lesions also presented a significant association with cryptogenic IS (adjusted OR = 0.4; 95 percent CI: 0.2-0.9). The association between PFO and cryptogenic IS met all the causality criteria. CONCLUSION: The causal relation between PFO and cryptogenic IS in the young population is highly probable. This fact should be considered in the therapeutic decision.