ACERTO Project - 15 years changing perioperative care in Brazil.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Acerto Project - 15 years changing perioperative care in Brazil / Projeto Acerto - 15 anos modificando cuidados perioperatórios no Brasil

ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.

Regional Anesthesia in Patients of Aged 99 Years in Clopidogrel Use.

The risk of neuraxial block in patients treated with antiplatelet drugs are uncertain. Elderly patients often have low physiological reserve, delaying surgery can lead to a high rate of morbidity and mortality. The aim of this paper is to present a case of a patient with 99 years using clopidogrel undergoing regional anesthesia for surgical treatment of hip fracture without complications.

Attitudes, awareness and barriers regarding evidence-based orthopedic surgery between health professionals from a Brazilian Public Health System (SUS) hospital: Study of 400 patients.

BACKGROUND: The fast-track concept refers to all phases of perioperative care: Preoperative, intraoperative, and postoperative strategies. Although most research has focused on adherence to medication, adherence also encompasses numerous health-related behaviors. The aim of this prospective study was to determine the attitudes and awareness among health professionals involved in the treatment of elderly patients with fractures of the femur and the results of 400 patients. METHODS: The postoperative protocol acceleration was presented to various hospital departments through four seminars. Questionnaire with four ex-residents in the Department of Anesthesiology was conducted. Every 6 months, the results of project implementation to all departments were presented. It was considered adherence to the project when the professionals agreed with all the steps and routines of the project. Patients underwent spinal anesthesia with postoperative analgesia by lumbar plexus block. RESULTS: All departments involved in the treatment of elderly patients' adhered completely to the project and reported the importance of preanesthetic visit, the explanations of design, and reduction of fasting period. Just one anesthetist completely adhered to the project. No former resident of anesthesia joined the program. All parameters studied in 400 patients compared with the data before the project showed a reduction from 21.38% to 100%. CONCLUSION: Improving adherence requires a continuous and dynamic process. We can be inferred that the implementation of fast-track project Brazilian Public Health System (Sistema Único Saúde, SUS) costs decreased with elderly patients with hip fractures. The anesthesiologist was the major obstacle to deployment to all patients.

Continuous posterior lumbar plexus and continuous parasacral and intubation with lighted stylet for ankylosing spondylitis.

Ankylosing spondylitis is characterized by progressive ossification of the spinal column with resultant stiffness. Ankylosing spondylitis can present significant challenges to the anaesthetist as a consequence of the potential difficult airway and performing neuraxial blockade. We describe a case of intubation with lighted stylet, and use of the continuous lumbosacral plexus for THA and postoperative analgesia with an elastomeric pump. Key words: Airways difficult anticipated, anesthesia, ankoylosing spondylitis, arthroplasty, conduction, continuous lumbosacral plexus, hip, infusion pumps, intubation awake, replacement.

Reduced fasting time improves comfort and satisfaction of elderly patients undergoing anesthesia for hip fracture / A diminuição do tempo de jejum melhora o conforto e satisfação com anestesia em pacientes idosos com fratura de quadril / La disminución del tiempo de ayuno mejora el bienestar y la satisfacción con la anestesia en pacientes ancianos con fractura de cadera

BACKGROUND AND OBJECTIVES: Patient's satisfaction is a standard indicator of care quality. The aim of this study was to evaluate whether a preoperative oral ingestion of 200 mL of a carbohydrate drink can improve comfort and satisfaction with anesthesia in elderly patients with hip fracture. METHOD: Prospective randomized clinical trial conducted in a Brazilian public hospital, with patients ASA I-III undergoing surgery for hip fracture. The control group (NPO) received nothing by mouth after 9:00 p.m. the night before, while patients in the experimental group (CHO) received 200 mL of a carbohydrate drink 2-4 h before the operation. Patients' characteristics, subjective perceptions, thirst and hunger and satisfaction were determined in four steps. Mann-Whitney U-test and Fisher exact test were used for comparison of control and experimental groups. A p-value <0.05 was considered significant. RESULTS: A total of 100 patients were included in one of the two regimens of preoperative fasting. Fasting time decreased significantly in the study group. Patients drank 200 mL 2:59 h before surgery and showed no hunger (p < 0.00) and thirst on arrival to OR (p < 0.00), resulting in increased satisfaction with the perioperative anesthesia care (p < 0.00). CONCLUSIONS: The satisfaction questionnaire for surgical patient could become a useful tool in assessing the quality of care. In conclusion, CHO significantly reduces preoperative discomfort and increases satisfaction with anesthesia care. .

JUSTIFICATIVA E OBJETIVOS: A satisfação do paciente é indicador padrão da qualidade da assistência prestada. O objetivo deste estudo foi avaliar se a ingestão de 200 mL oral pré-operatória de uma bebida de carboidratos pode melhorar o conforto e a satisfação com a anestesia no paciente idoso com fratura de quadril. MÉTODO: Ensaio clínico prospectivo e randomizado realizado em hospital público de saúde brasileiro, pacientes estado físico ASA I-III submetidos à cirurgia de fratura de quadril. O grupo controle (NPO) não recebeu nada pela boca, após as 21 horas da noite anterior, enquanto que os pacientes no grupo experimental (CHO) recebeu 200 mL de uma bebida de carbohidratos de 2 a 4 horas antes da operação. Características dos pacientes, percepções subjetivas, presença de sede e fome e satisfação dos pacientes foi apurado em quatro etapas. Teste de Mann-Whitney U-test e exato de Fisher foram utilizados entre o grupo controle e o grupo experimental. Valor de p < 0,05 foi considerado significativo. RESULTADOS: Um total de 100 pacientes foram incluídos em um dos dois regimes de jejum pré-operatório. Tempo de jejum diminuiu significativamente no grupo de estudo. Pacientes beberam 200 mL 2:59 h antes da cirurgia e não apresentaram fome (p < 0,00) e sede na chegada à SO (p < 0,00), resultando em aumento da satisfação com o cuidado perioperatório anestesia (p < 0,00). CONCLUSÕES: O questionário de satisfação do paciente cirúrgico poderia tornar-se um instrumento útil na avaliação da qualidade de atendimento. Em conclusão, CHO reduz significativamente o desconforto pré-operatório e satisfação com os cuidados da anestesia. .

JUSTIFICACIÓN Y OBJETIVOS: La satisfacción del paciente es un indicador estándar de la calidad de la asistencia prestada. El objetivo de este estudio fue evaluar si la ingestión oral preoperatoria de 200 ml de una bebida de hidratos de carbono puede mejorar el bienestar y la satisfacción con la anestesia en el paciente anciano con fractura de cadera. MÉTODO: Ensayo clínico prospectivo y aleatorizado realizado en un hospital público brasileño, en pacientes estado físico ASA I-III sometidos a cirugía de fractura de cadera. El grupo control no recibió nada por la boca, después de las 21 h de la noche anterior, mientras que los pacientes en el grupo experimental recibieron 200 ml de una bebida de hidratos de carbono 2-4 h antes de la operación. Se investigaron características de los pacientes, percepciones subjetivas, presencia de sed y hambre, y satisfacción de los pacientes en 4 etapas. El test U de Mann-Whitney y el exacto de Fisher fueron utilizados en el grupo control y el grupo experimental. Un valor de p < 0,05 fue considerado significativo. RESULTADOS: Un total de 100 pacientes fueron incluidos en uno de los 2 regímenes de ayuno preoperatorio. El tiempo de ayuno disminuyó significativamente en el grupo de estudio. Los pacientes bebieron 200 ml 2:59 h antes de la cirugía y no sintieron hambre (p < 0,00) ni sed a su llegada al quirófano (p < 0,00), lo que trajo un aumento de la satisfacción con el cuidado perioperatorio anestésico (p < 0,00). CONCLUSIONES: El cuestionario de satisfacción del paciente quirúrgico podría convertirse en un instrumento útil para la evaluación de la calidad de la atención. Como conclusión, podemos decir que los hidratos de carbono reducen significativamente el malestar preoperatorio y aumentan la satisfacción con los cuidados de la anestesia. .

[Reduced fasting time improves comfort and satisfaction of elderly patients undergoing anesthesia for hip fracture]. / A diminuição do tempo de jejum melhora o conforto e satisfação com anestesia em pacientes idosos com fratura de quadril.

BACKGROUND AND OBJECTIVES: Patient's satisfaction is a standard indicator of care quality. The aim of this study was to evaluate whether a preoperative oral ingestion of 200mL of a carbohydrate drink can improve comfort and satisfaction with anesthesia in elderly patients with hip fracture. METHOD: Prospective randomized clinical trial conducted in a Brazilian public hospital, with patients ASA I-III undergoing surgery for hip fracture. The control group (NPO) received nothing by mouth after 9:00 p.m. the night before, while patients in the experimental group (CHO) received 200mL of a carbohydrate drink 2-4hours before the operation. Patients' characteristics, subjective perceptions, thirst and hunger and satisfaction were determined in four steps. Mann-Whitney U-test and Fisher exact test were used for comparison of control and experimental groups. A p-value <0.05 was considered significant. RESULTS: A total of 100 patients were included in one of two regimens of preoperative fasting. Fasting time decreased significantly in the study group. Patients drank 200mL 2:59h before surgery and showed no hunger (p <0.00) and thirsty on arrival to OR (p <0.00), resulting in increased satisfaction with the perioperative anesthesia care (p <0.00). CONCLUSIONS: The satisfaction questionnaire for surgical patient could become a useful tool in assessing the quality of care. In conclusion, CHO significantly reduces preoperative discomfort and increases satisfaction with anesthesia care.

Spinal anesthesia for laparoscopic cholecystectomy: Thoracic vs. Lumbar Technique.

AIMS: In our group, after a study showing that spinal anesthesia is safe when compared with general anesthesia, spinal anesthesia has been the technique of choice for this procedure. This is a prospective study with all patients undergoing LC under spinal anesthesia in our department since 2007. SETTINGS AND DESIGN: Prospective observational. MATERIALS AND METHODS: From 2007 to 2011, 369 patients with symptoms of colelithiasis, laparoscopic cholecystectomy were operated under spinal anesthesia with pneumoperitoneum and low pressure CO2. We compared 15 mg of hyperbaric bupivacaine and lumbar puncture with 10 or 7.5 mg of hyperbaric bupivacaine thoracic puncture, all with 25 µg fentanyl until the sensory level reached T3. Intraoperative parameters, post-operative pain, complications, recovery, patient satisfaction, and cost were compared between both groups. STATISTICAL ANALYSIS USED: Means were compared by ANOVA or Kruskal-Wallis test, the percentages of the Chi-square test or Fisher's exact test when appropriate. Time of motor and sensory block in spinal anesthesia group was compared by paired t test or Mann-Whitney test. Differences were considered significant when P ≤ 0.05, and for comparisons of mean pain visual scale, we employed the Bonferroni correction applied to be considered significant only with P ≤ 0.0125. RESULTS: All procedures were completed under spinal anesthesia. The use of lidocaine 1% was successful in the prevention of shoulder pain in 329 (89%) patients. There were significant differences in time to reach T3, obtaining 15 mg > 10 mg = 7.5 mg. There is a positive correlation between the dose and the incidence of hypotension. The lowest doses gave a decrease of 52.2% in the incidence of hypotension. There was a positive correlation between the dose and duration of sensory and motor block. Sensory block was almost twice the motor block at all doses. With low doses, 60% of patients went from table to stretcher. Satisfaction occurred in 99% of patients. CONCLUSIONS: Laparoscopic cholecystectomy can be performed successfully under spinal anesthesia with low-pressure pneumoperitoneum of CO2. The use of thoracic puncture and low doses of hyperbaric bupivacaine provided better hemodynamic stability, less hypotension, and shorter duration of sensory and motor blockade than lumbar spinal anesthesia with conventional doses.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery.

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures. METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation. RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day. CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

Successful anesthesia and hip surgery in a 107-year-old patient.

PATIENT: Female, 107. FINAL DIAGNOSIS: Hip fracture. SYMPTOMS: -. MEDICATION: -. CLINICAL PROCEDURE: Hip surgery. SPECIALTY: Orthopedics and Traumatology. OBJECTIVE: Rare disease. BACKGROUND: In modern societies, elderly populations have increased over the last four decades and have become the main clients of medical services. A hip fracture is a significant injury for anyone, but for older people it can be catastrophic. CASE REPORT: A 107-year-old female was admitted with fracture of the right hip. The patient took a single 200 mL carbohydrate drink orally two hours before surgery. Before induction of spinal anesthesia, routine monitoring was started and an intravenous line was placed. Crystalloids and hydroxyethyl starch in 0.9% sodium chloride solution were administered intravenously during the operation. After sedation with i.v. ketamine and midazolam, spinal puncture was performed with the patient in the sitting position and isobaric bupivacaine were administered. The level of sensory block was observed in T12 and motor blockade (grade 3) of the lower limbs. The surgical procedure lasted 60 minutes without hypotension, bradycardia or decreased oxygen saturation. For safety reason, the patient was transferred to the ICU for monitoring; intravenous hydration was withdrawn and released oral feeding six hours after the end of surgery. The patient was sent to his residence on the morning of the second day. CONCLUSIONS: This case showed that with suitable techniques and conduits can perform surgery in a patient with 107 years.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery / Avaliação dos resultados da implantação de um protocolo de cuidados perioperatórios em pacientes submetidos à cirurgia ortopédica

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures. METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation. RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day. CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures. .

OBJETIVO: avaliar os resultados clínicos iniciais após a implantação de protocolo perioperatório em pacientes com mais de 60 anos de idade submetidos ao tratamento cirúrgico de fratura do fêmur. MÉTODOS: estudo prospectivo com pacientes com idade superior a 60 anos que foram internados com fratura de fêmur. Operados sob raquianestesia e analgesia através do bloqueio plexo lombar. A avaliação dos dados foi realizada antes da chegada ao centro cirúrgico, durante o procedimento cirúrgico, na sala de recuperação pós-anestésica e, na enfermaria, na manhã seguinte da operação. RESULTADOS: os 105 pacientes foram submetidos a diversos tipos de correção cirúrgica no fêmur. A internação variou de três a 86 dias. O jejum variou de 9h15min a 19h30min. Hipotensão arterial ocorreu em 5,7%. A duração do bloqueio motor variou de 1h45min a 5h30min, a alimentação com maltodextrina variou de 50min a 3h45min e o tempo de permanência na sala de recuperação pós-anestésica variou de 50min a 4 horas. A alimentação oral na enfermaria variou de 4h a 8h15min. A duração da analgesia variou de 14 a 33 horas. Nenhum paciente necessitou de sonda vesical de demora, nem foi encaminhado à UTI. Todos os pacientes tinham condições de alta hospitalar no primeiro dia de pós-operatório. . CONCLUSÃO: a utilização de um projeto de aceleração do pós-operatório pode diminuir o tempo de jejum, a duração da internação e proporcionar alta hospitalar mais rápida em pacientes idosos com fratura de fêmur. .

A comparison of thoracic spinal anesthesia with low-dose isobaric and low-dose hyperbaric bupivacaine for orthopedic surgery: A randomized controlled trial.

BACKGROUND: The thoracic spinal anesthesia was first described in 1909 and recently revised for various surgical procedures. This is a prospective study aims to evaluate the parameters of the thoracic spinal anesthesia (latency, motor block and paresthesia), the incidence of cardiovascular changes and complications comparing low doses of isobaric and hyperbaric bupivacaine. MATERIALS AND METHODS: A total of 200 orthopedic patients operated under spinal anesthesia were included in this study. Spinal anesthesia was between T9-T10, with a 27G cutting point or pencil tip in lateral or sitting. Spinal anesthesia was performed with 0.5% bupivacaine isobaric or hyperbaric. Patients remained in cephalad or head down position 10-20° for 10 minutes. We evaluated the demographics, analgesia, and degree of motor block, incidence of paresthesia, bradycardia, hypotension, anesthesia success and neurological complications. RESULTS: All patients developed spinal and there was no failure. The solution did not affect the onset of the blockade. The duration of motor block was greater than the sensitive with isobaric. The duration of sensory block was greater than the motor block with hyperbaric solution. The incidence of paresthesia was 4%, with no difference between the needles. The incidence of hypotension was 12.5% with no difference between the solutions. There was no neurological damage in all patients. CONCLUSION: The beginning of the block is fast regardless of the solution used. By providing a sensory block of longer duration than the motor block hyperbaric bupivacaine is reflected in a better indication. Thoracic spinal anesthesia provides excellent anesthesia for lower limb orthopedic surgery.

Clinical strategies to accelerate recovery after surgery orthopedic femur in elderly patients.

BACKGROUND: The prevalence of hip fracture is increasing with the continued aging of the population. The aim of this study was to compare the results after implementing the project accelerated post-operative recovery after surgery femur in patients aged over 60 years. METHODS: Patients were observed during two distinct periods: Before implantation and after the implementation of the project Acerto. Patients underwent spinal anesthesia with post-operative analgesia by lumbar plexus block. Data evaluation was carried out in four stages of the study in both groups: Before arrival to the operating room during surgery, post-anesthesia care unit and on the ward in the morning of day 1 post-operatively. RESULTS: The project implementation significantly reduces the length of stay, the number of suspension of surgery, duration of fasting, the incidence of hunger and thirst and the reintroduction of oral feeding. Oral feeding 2-4 h before surgery with dextrinomaltose not attended with nausea and vomiting. All patients were able to discharge on day 1 post-operatively. CONCLUSIONS: The use of clinical measures of accelerating patient recovery decreased length of stay, the number of suspensions of surgery, the time of fasting, the time of oral food reintroduction, high earlier and faster return to family life, working as humanization of treatment to the elderly.

Spinal hemianesthesia: Unilateral and posterior.

The injection of a non-isobaric local anesthetic should induce a unilateral spinal anesthesia in patients in a lateral decubitus position. The posterior spinal hemianesthesia only be obtained with hypobaric solutions injected in the jackknife position. The most important factors to be considered when performing a spinal hemianesthesia are: type and gauge of the needle, density of the local anesthetic relative to the CSF, position of the patient, speed of administration of the solution, time of stay in position, and dose/concentration/volume of the anesthetic solution. The distance between the spinal roots on the right-left sides and anterior-posterior is, approximately, 10-15 mm. This distance allows performing unilateral spinal anesthesia or posterior spinal anesthesia. The great advantage of obtaining spinal hemianesthesia is the reduction of cardiovascular changes. Likewise, both the dorsal and unilateral sensory block predominates in relation to the motor block. Because of the numerous advantages of producing spinal hemianesthesia, anesthesiologists should apply this technique more often. This review considers the factors which are relevant, plausible and proven to obtain spinal hemianesthesia.

A new, lateral, continuous, combined, femoral-sciatic nerve approach via a single skin puncture for postoperative analgesia in intramedullary tibial nail insertion.

BACKGROUND: The prevalence of anterior knee pain following intramedullary tibial nail insertion is high. Continuous peripheral nerve blockade is an alternative method of pain control to opiods. This case illustrates the use of femoral nerve and sciatic nerve peripheral catheters with an elastomeric infusion pump for major intramedullary nailing surgery. CASE REPORT: A 36-year-old male with fractures to the left leg bones presented for placement of an intramedullary nail under spinal anesthesia. At the end of the procedure, access to the lateral femoral and sciatic continuous nerve block was achieved by using a stimulator connected to a 110 mm 18G Tuohy needle. Postoperative analgesia was provided with a 40-hour infusion of 0.1% bupivacaine (400 mL) at a rate of 10 mL hour(-1) with an elastomeric pump. Anesthetic dispersion and contrast were investigated. The analog scale remained with scores below 3 during the 40 hours after surgery, and boluses were not necessary. CONCLUSION: The use of a femoral and sciatic nerve peripheral catheter offered an alternative to conventional pain control. Continuous femoral-sciatic peripheral blockade via a skin puncture with an infusion of 0.1% bupivacaine with elastomeric pumps is a safe and effective procedure in adults.

Diminuição da concentração da levobupivacaína em excesso enantiomérico (S75: R25) para 0, 4% hiperbárica proporciona raquianestesia unilateral: estudo com diferentes volumes / Reducing the concentration to 0. 4% enantiomeric excess hyperbaric levobupivacaine (S75: R25) provides unilateral spinal anesthesia: study with different volumes / Disminución de la concentración de la levobupivacaína en exceso enantiomérico (S75: R25) para 0, 4% hiperbárica que proporciona raquianestesia unilateral: estudio con diferentes volúmenes

JUSTIFICATIVA E OBJETIVOS: Raquianestesia unilateral pode-se obter com solução hipobárica ou hiperbárica. O objetivo deste estudo foi comparar diferentes doses de levobupivacaína em excesso enantiomérico hiperbárico para se obter raquianestesia unilateral. PACIENTES E MÉTODO: Cento e vinte pacientes foram aleatoriamente separados para receber 4 mg, 6 mg ou 8 mg de levobupivacaína em excesso enantiomérico a 0,4%. As soluções foram administradas entre L3-L4, em posição lateral e permanecendo nessa posição em 5, 10 ou 15 minutos de acordo com a dose empregada. Bloqueios sensitivo (picada de agulha) e motor (escala de 0 a 3) foram comparados entre o lado a ser operado e contralateral. RESULTADOS: O início da analgesia foi rápido e comparável entre os grupos. Em todos os momentos das avaliações o bloqueio sensitivo no membro operado foi significativamente mais alto do que no membro não operado. O aumento de 1 mL (2 mg) na dose correspondeu a um aumento de dois segmentos (moda) no lado operado. No lado operado, o bloqueio motor completo (BM = 3) ocorreu em 31 (77,5%) dos pacientes com 4 mg, 38 (95%) com 6 mg e 40 (100%) com 8 mg. Houve uma correlação positiva entre o aumento da dose, a duração do bloqueio e a hipotensão. Todos os pacientes tiveram uma satisfação ótima com a técnica usada. CONCLUSÕES: A raquianestesia com diferentes volumes da solução de levobupivacaína em excesso enantiomérico (S75:R25) hiperbárica proporcionou uma incidência de 78% de unilateralidade do bloqueio espinal, sendo a menor dose empregada (4 mg) a mais eficiente.

BACKGROUND AND OBJECTIVES: Unilateral spinal anesthesia may be obtained with hypobaric or hyperbaric solution. The objective of this study was to compare different doses of enantiomeric excess hyperbaric levobupivacaine to achieve unilateral spinal anesthesia. METHOD: One hundred and twenty patients were randomized to receive 4 mg, 6 mg or 8 mg of 0.4% enantiomeric excess levobupivacaine. The solutions were administered at the L3-L4, with the patient in a lateral position and kept at this position according to dose administration for 5, 10 or 15 minutes. Sensory block (pinprick) and motor block (scale 0-3) were compared between the operated and contralateral sides. RESULTS: The onset of analgesia was rapid and comparable between groups. Sensory block was significantly higher in the operated than in nonoperated limb at all times of evaluation. Increasing the dose by 1 mL (2 mg) corresponded to an increase of two segments in the mode for the operated side. In the operated side, motor block (MB = 3) of patients occurred in 31 (77.5%) with 4mg, 38 (95%) with 6 mg, and 40 (100%) with 8 mg. There was a positive correlation between increased dose, blockade duration, and hypotension. All patients were satisfied with the technique used. CONCLUSIONS: Spinal anesthesia with different volumes of enantiomeric excess hyperbaric bupivacaine (S75: R25) provided a 78% incidence of unilateral spinal block, with the smallest dose used (4 mg) the most efficient.

JUSTIFICATIVA Y OBJETIVOS: La Raquianestesia unilateral se puede obtener con una solución hipobárica o hiperbárica. El objetivo de este estudio, fue comparar las diferentes dosis de levobupivacaína en exceso enantiomérico hiperbárico para poder obtener la raquianestesia unilateral. PACIENTES Y MÉTODO: Ciento veinte pacientes fueron aleatoriamente separados para recibir 4 mg, 6 mg u 8 mg de levobupivacaína en exceso enantiomérico al 0,4%. Las soluciones fueron administradas entre L3-L4, en posición lateral permaneciendo en esa posición en 5, 10 ó 15 minutos de acuerdo con la dosis usada. Los bloqueos sensitivo (picada de aguja) y motor (escala de 0 a 3) se compararon entre el lado que sería operado y el lado contralateral. RESULTADOS: El inicio de la analgesia fue rápido y se comparó entre los grupos. En todos los momentos de las evaluaciones, el bloqueo sensitivo en el miembro operado fue significativamente más alto que en el miembro no operado. El aumento de 1 mL (2 mg) en la dosis correspondió a un aumento de los segmentos en la moda en el lado operado. En el lado operado, el bloqueo motor completo (BM = 3) se dio en 31 (77,5%) de los pacientes con 4 mg, 38 (95%) con 6 mg y 40 (100%) con 8 mg. Hubo una correlación positiva entre el aumento de la dosis, la duración del bloqueo y la hipotensión. Todos los pacientes alcanzaron una excelente satisfacción con la técnica usada. CONCLUSIONES: La raquianestesia con diferentes volúmenes de la solución de levobupivacaína en exceso enantiomérico (S75:R25) hiperbárica, proporcionó una incidencia de un 78% de unilateralidad del bloqueo espinal, siendo la menor dosis usada (4 mg) la más eficiente.

Reducing the concentration to 0.4% enantiomeric excess hyperbaric levobupivacaine (s75: r25) provides unilateral spinal anesthesia. Study with different volumes.

BACKGROUND AND OBJECTIVES: Unilateral spinal anesthesia may be obtained with hypobaric or hyperbaric solution. The objective of this study was to compare different doses of enantiomeric excess hyperbaric levobupivacaine to achieve unilateral spinal anesthesia. METHOD: One hundred and twenty patients were randomized to receive 4 mg, 6 mg or 8 mg of 0.4% enantiomeric excess levobupivacaine. The solutions were administered at the L3-L4, with the patient in a lateral position and kept at this position according to dose administration for 5, 10 or 15 minutes. Sensory block (pinprick) and motor block (scale 0-3) were compared between the operated and contralateral sides. RESULTS: The onset of analgesia was rapid and comparable between groups. Sensory block was significantly higher in the operated than in nonoperated limb at all times of evaluation. Increasing the dose by 1 mL (2mg) corresponded to an increase of two segments in the mode for the operated side. In the operated side, motor block (MB = 3) of patients occurred in 31 (77.5%) with 4 mg, 38 (95%) with 6 mg, and 40 (100%) with 8 mg. There was a positive correlation between increased dose, blockade duration, and hypotension. All patients were satisfied with the technique used. CONCLUSIONS: Spinal anesthesia with different volumes of enantiomeric excess hyperbaric bupivacaine (S75: R25) provided a 78% incidence of unilateral spinal block, with the smallest dose used (4 mg) the most efficient.

Postoperative analgesia for hemorrhoidectomy with bilateral pudendal blockade on an ambulatory patient: a controlled clinical study

BACKGROUND AND OBJECTIVES: Reducing postoperative pain in hemorrhoidectomy is still a challenge. This prospective, randomized, double-blind study was conducted to compare bilateral pudendal blockade with peripheral nerve stimulator to relieve postoperative pain with the method commonly used. METHOD: 200 patients scheduled for hemorrhoidectomy were randomly divided into Control Group and Pudendal Group. Bilateral pudendal block was performed with levobupivacaine enantiomeric excess (S75:R25) after location with a peripheral nerve stimulator. The parameters evaluated were pain intensity, duration of analgesia, rescue analgesia, complications, patient satisfaction and pain at first defecation. Data were recorded at 6, 12, 18 and 24 hours after the surgery. RESULTS: Bilateral pudendal nerves with mean 23.4±4.4 hours provided better relief of postoperative pain (p<0.001), reducing the need for analgesics and residual analgesia for more than 24 hours in 41% of patients. All patients in Pudental Group had spontaneous micturition versus 96 in the control group. There was no local or systemic complications. CONCLUSIONS: Bilateral blockade of the pudendal nerve using a neurostimulator provided better pain relief with less need for rescue dose and no local or systemic complications. (AU)

JUSTIFICATIVA E OBJETIVOS: A dor pós-operatória em hemorroidectomia ainda é um problema desafiador. Este estudo prospectivo, aleatório, duplamente encoberto, foi realizado para comparar o bloqueio bilateral do pudendo com estimulador de nervos periféricos para alívio da dor pós-operatória ao método habitualmente utilizado. MÉTODO: 200 pacientes escalados para hemorroidectomia foram aleatoriamente separados em Grupo Controle e Grupo Pudendo. O bloqueio bilateral do Grupo Pudendo foi realizado com levobupivacaína em excesso enantiomérico (S75:R25) após localização com estimulador de nervo periférico. Os parâmetros avaliados foram: intensidade da dor, duração da analgesia, resgate de analgésico, complicações, satisfação dos pacientes e dor à primeira defecação. Os dados foram anotados as 6, 12, 18 e 24 horas após a cirurgia. RESULTADO: O bloqueio bilateral dos pudendos, com média de 23,4±4,4 horas proporcionou um melhor alívio da dor pós-operatória (p<0,001), reduzindo a necessidade de analgésicos e com analgesia residual maior de 24 horas em 41% dos pacientes. Todos do Grupo Pudendo tiveram micção espontânea contra 96 do Grupo Controle. Não se observaram complicações locais ou sistêmicas. CONCLUSÕES: O bloqueio bilateral dos nervos pudendos com neuroestimulador proporcionou melhor alívio da dor, com menor necessidade de dose de resgate e sem complicações locais ou sistêmicas. (AU)